LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required LPN-to-resident staffing ratios on multiple occasions, as evidenced by a review of nursing schedules and staffing information. On December 31, 2024, the facility had a census of 85 residents, necessitating 2.83 LPNs for the evening shift, but only 2.40 LPNs were scheduled. On January 1, 2025, with a census of 84 residents, the day shift required 3.36 LPNs, yet only 3.30 LPNs were present. Additionally, the night shift on the same day required 2.10 LPNs, but only 1.18 LPNs were available. On January 3, 2025, the facility census was 86, requiring 3.44 LPNs for the day shift, but only 2.86 LPNs were scheduled. On January 5, 2025, with a census of 87 residents, the day shift required 3.48 LPNs, but only 3.27 LPNs were present, and the night shift required 5.80 LPNs, but only 5.44 LPNs were scheduled. The deficiency was confirmed through an interview with the Nursing Home Administrator on January 15, 2025, who acknowledged that the facility did not meet the required LPN-to-resident staffing ratios on the specified days. The report indicates that no additional higher-level staff were available to compensate for the staffing shortfalls, leading to non-compliance with the regulation effective July 1, 2023, which mandates specific LPN-to-resident ratios for different shifts.
Plan Of Correction
1. The facility cannot retroactively correct nursing staffing hours and ratios. 2. The facility is focusing on the retention of existing nursing staff and recruiting new staff through the efforts of the staffing committee and human resource department. 3. The Executive Director (ED) re-educated the scheduler and nursing supervisors on the staffing ratios and hours per patient day (HPPD). Staffing meetings to review the calculations for nursing staff ratios and HPPD for accuracy. 4. The ED or Designees to conduct Quality Improvement (QI) monitoring of daily schedules to ensure the ratio of care/minimum PPD will be met. QI monitoring conducted via OnShift Daily Schedules reviewed weekly x 4 weeks, then once a month as needed. Findings reported to the Quality Improvement Performance Improvement (QAPI) committee and updated as indicated. QI monitoring schedule modified based on findings.