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P5530

LPN Staffing Shortages in Facility

Edinboro, Pennsylvania Survey Completed on 01-08-2025

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 staffing ratios for Licensed Practical Nurses (LPNs) on multiple occasions between December 31, 2024, and January 6, 2025. Specifically, the facility did not have the minimum number of LPNs per resident during the day, evening, and overnight shifts on several days. On January 2 and January 5, 2025, the day shift was understaffed with 4.06 and 4.25 LPNs working, respectively, when 4.52 and 4.64 were required based on the resident census. Similarly, the evening shift on January 3 and January 6, 2025, was short with 3.59 and 3.43 LPNs working, while 3.77 and 3.90 were needed. The overnight shift also experienced shortages on December 31, 2024, and January 2 and 3, 2025, with fewer LPNs than required. The Nursing Home Administrator confirmed during a telephone interview on January 8, 2025, that the facility did not meet the minimum LPN staffing ratios on the specified days and shifts. This deficiency was identified through a review of the facility's nursing staffing documents and staff interviews, highlighting a failure to comply with the regulation effective July 1, 2023, which mandates specific LPN-to-resident ratios for different shifts.

Plan Of Correction

The Administrator and/or designee will provide education to the staffing coordinator, charge nurses, and administrative nurses on the state required minimum staffing ratios for licensed practical nurse requirements. The Administrator and/or designee will review staffing sheets 4 times a week for 2 weeks, and 3 times weekly for 4 weeks to ensure that the state required minimum staffing ratios for licensed practical nurses are met per regulation. All audits will be reviewed through the Quality assurance/performance improvement process. The Administrator and/or designee will utilize recruitment platforms and Indeed for job applicants, attend job fairs as able, corporate talent acquisition specialist, employee referral bonus program, and tuition reimbursement for recruitment efforts. Charge Nurses will be provided with employee contact listings and will be responsible for calling staff when ratios are projecting to be unmet. They will be able to offer our hourly call-in pay to help with incentive shift pick-ups. Call offs are to be addressed by these charge nurses to ensure that the staffing requirements are met.

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