LPN Staffing Shortages Identified
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) as mandated by the regulation effective July 1, 2023. Specifically, the facility did not provide the minimum of one LPN per 25 residents during the day shift on one occasion, one LPN per 30 residents during the evening shift on six occasions, and one LPN per 40 residents during the night shift on six occasions within a 14-day period. This deficiency was identified through a review of nursing time schedules and confirmed by the Nursing Home Administrator during an interview. The census data and actual hours worked by LPNs were consistently below the required hours, leading to the staffing shortages on the specified dates.
Plan Of Correction
The facility cannot retroactively correct cited deficiencies. The facility will continue to maintain the required ratios and implement a contingency plan if needed by calling in off duty staff, calling sister facilities or utilizing agency as needed to ensure sufficient nursing staff. The RDO educated NHA/DON on ensuring sufficient nursing staff. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 5x weekly x4 weekly then monthly x2 to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.