LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratio on multiple occasions, as evidenced by a review of staffing records and staff interviews. Specifically, on December 8, 2024, the facility had only 3.00 LPNs on the day shift, whereas 3.68 LPNs were required for a census of 92 residents. Additionally, on December 5, 8, 9, and 10, 2024, the night shift was staffed with only 2.00 LPNs, falling short of the required 2.3 to 2.4 LPNs for resident censuses ranging from 92 to 96. The Director of Nursing confirmed these staffing deficiencies during an interview on January 3, 2025, and no additional higher-level staff were available to compensate for the shortfall.
Plan Of Correction
P5530 Nursing Services 1. The facility is unable to correct LPN staffing ratio on December 5, 2024, December 8, 2024, December 9, 2024 and December 10, 2024. 2. No other dates were identified during the survey. 3. To prevent this from reoccurring, the DON/designee completed education with the Nursing supervisors and the scheduler to maintain LPN ratio with current census. If call offs occur, the supervisor needs to call staff and post on agency sites for the open shift. Recruitment of nursing staff will continue via facility website, indeed, social media websites, job fairs and off-site recruiters. Agency will be utilized for open shifts as needed and available. 4. To monitor and maintain ongoing compliance, the DON/designee will audit the schedule weekly x4, biweekly x 4 and monthly x 2 to ensure the LPN ratio has been met. Results will be reviewed at the QAPI meeting. 5. 1/16/2025