Failure to Meet LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum staffing ratios for Licensed Practical Nurses (LPNs) on specific shifts. On December 31, 2024, during the evening shift, the facility had a census of 127 residents but only maintained an LPN ratio of 4.0, falling short of the required 4.23. Additionally, on the same date and the night shift of January 1, 2025, the facility had the same census of 127 residents but only maintained an LPN ratio of 3.0, below the required 3.18. These deficiencies were confirmed by the Nursing Home Administrator during an interview on January 9, 2025, who acknowledged the accuracy of the staffing information and the failure to meet the required LPN ratios on the specified shifts.
Plan Of Correction
1) Facility cannot retroactively correct. 2) NHA/designee will review LPN staffing ratios for the last 4 weeks to ensure compliance and adherence to regulation. 3) NHA/Designee will re-educate staff scheduler and DON on regulation of LPN staffing ratios to ensure ongoing compliance. Facility will conduct daily staffing meeting to review LPN ratios to ensure ongoing compliance and systematic change. Facility will educate nursing staff on call off policy and hold weekly meeting to review call offs and enforce disciplinary action per call off policy. 4) NHA/Designee will conduct audit of projected LPN ratios 3 x a week x 4 weeks and once a month x 2 months to ensure compliance with regulation. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until substantial compliance is met.