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P5530

LPN Staffing Deficiency Across Multiple Shifts

Tamaqua, Pennsylvania Survey Completed on 01-02-2025

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 required licensed practical nurse (LPN) to resident ratios across multiple shifts, as evidenced by a review of staffing records. Specifically, the facility did not provide the minimum LPN staffing levels on 14 out of 21 shifts reviewed. On the day shift, the facility consistently fell short of the required 1 LPN per 25 residents, with staffing levels ranging from 2.91 to 4.06 LPNs for a census of 102 residents, where 4.08 LPNs were required. Similarly, the evening shift did not meet the required 1 LPN per 30 residents, with staffing levels between 2.06 and 3.22 LPNs for a census of 101 to 102 residents, where 3.37 to 3.40 LPNs were needed. The night shift also failed to meet the required 1 LPN per 40 residents, with staffing levels ranging from 1.38 to 2.19 LPNs for a census of 100 to 103 residents, where 2.50 to 2.58 LPNs were necessary. The Director of Nursing confirmed that no additional higher-level staff were available to compensate for these deficiencies. This lack of adequate staffing was confirmed during an interview with the Director of Nursing, who acknowledged the facility's failure to meet the required LPN to resident ratios on the specified dates.

Plan Of Correction

1. Facility cannot retroactively correct past LPN ratios. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilize agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary ratios. Nursing scheduler was educated on this new process. 4. NHA will audit LPN ratios weekly for 4 weeks and then monthly for 2 months to ensure LPN ratios are met. 5. Audits will be submitted to QAPI for review.

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