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P5530

LPN Staffing Shortages During Night Shift

Murrysville, Pennsylvania Survey Completed on 12-10-2024

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet the regulatory requirement of providing a minimum of one Licensed Practical Nurse (LPN) per 40 residents during the night shift on three specific dates. A review of the nursing time schedules and facility census data from November 24, 2024, through December 7, 2024, revealed that on November 25, 29, and December 1, 2024, the facility did not have the required number of LPNs on duty. Specifically, the facility had 1.97, 1.94, and 1.99 full-time equivalent (FTE) LPNs present, respectively, when 2.03 FTEs were required for the census of 81 residents. The Director of Nursing confirmed these staffing shortages during an interview, acknowledging the failure to meet the staffing requirement without any additional higher-level staff to compensate for the deficiency.

Plan Of Correction

1. The facility cannot correct that LPN staffing ratio was not met on 11/25/24, 11/29/24, and 12/1/24. There were no adverse effects to residents on the identified dates. 2. The facility will ensure that staffing ratios are met every shift. 3. Nursing administration and the scheduler will be re-educated by the Nursing Home Administrator/designee on ensuring staffing ratios are met each shift. Daily shift staffing ratios will be reviewed at Standup and Stand down. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects not to meet staffing ratios on a shift, nursing administration/designee will be responsible to call off duty personnel or call extra support staff to assist. 4. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.

See complete original report
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