Failure to Meet LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on six out of 21 shifts reviewed. Specifically, on December 22, 2024, the day shift had 3.22 LPNs instead of the required 4 for a census of 100 residents, the evening shift had 2.72 LPNs instead of 3.33, and the night shift had 2.03 LPNs instead of 2.5. On December 25, 2024, the day shift had 3.66 LPNs instead of 4 for a census of 100. On December 27, 2024, the night shift had 2.19 LPNs instead of 2.45 for a census of 98. On December 28, 2024, the evening shift had 2.97 LPNs instead of 3.20 for a census of 96. No additional higher-level staff were available to compensate for this deficiency. The Nursing Home Administrator confirmed the facility's failure to meet the required LPN to resident ratios on these dates.
Plan Of Correction
1. The facility cannot retroactively correct LPN staffing ratio. 2. DON/designee will conduct an initial audit of the past two weeks' schedule to determine if nurse aide ratio is in compliance. 3. DON/designee will re-educate the scheduler on the proper LPN staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made. 4. DON/designee will conduct random audits of LPN staffing weekly for four weeks, then monthly for two months thereafter to verify proper LPN ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.