LPN Staffing Deficiency on Night Shifts
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on two specific night shifts. On December 19 and December 20, 2024, the facility provided only 2.00 LPNs for a census of 103 residents, whereas the regulation required 2.58 LPNs. This deficiency was identified through a review of the facility's weekly staffing records, which showed that the minimum staffing levels were not met. Additionally, there were no higher-level staff available to compensate for this shortfall. The Nursing Home Administrator confirmed the failure to meet the required LPN to resident ratios during an interview on December 30, 2024.
Plan Of Correction
The facility cannot retroactively correct the deficiency. The Nursing Staffing Coordinator will be re-educated regarding the ratios for LPNs. The facility will focus on retention of existing LPNs and recruitment of new LPNs through efforts of the facility Recruitment & Retention Committee. Calculation of the daily LPN ratios will be completed and reviewed for accuracy by the scheduler/designee. Daily ratios will be audited weekly x4 then monthly x2. The audits will be taken to QAPI for further action planning as needed. Facility will be in compliance 02/15/2025.