LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) as mandated by the regulation effective July 1, 2023. Specifically, the facility did not maintain the minimum staffing levels of one LPN per 25 residents during the day shift, one LPN per 30 residents during the evening shift, and one LPN per 40 residents during the overnight shift. This deficiency was identified through a review of nursing staffing hours and confirmed by an interview with the Administrator. The review covered specific periods in November and December 2024, revealing multiple instances where the number of LPNs on duty was below the required levels. During the day shift, the facility was understaffed on six occasions, with the number of LPNs ranging from 4 to 4.16, while the required number ranged from 4.32 to 4.44 based on the census. The evening shift was understaffed on one occasion, with 3.44 LPNs instead of the required 3.63. The overnight shift showed the most significant deficiency, with 14 instances of understaffing, where the number of LPNs ranged from 2 to 2.08, while the required number ranged from 2.68 to 2.80. These findings indicate a consistent failure to meet the staffing requirements, potentially impacting the quality of care provided to the residents.
Plan Of Correction
P5530 1. Findings of LPN nursing staff care ratios cannot be retroactively corrected. 2. Facility will provide a minimum of one Licensed Practical Nurse per 25 residents during the day shift, a minimum of one LPN per 30 residents during the evening shift and a minimum of one LPN per 40 residents during the night shift. Staffing team will meet daily Monday-Friday to review staffing needs and create plans to ensure LPN coverage. 3. Scheduling manager will be educated on the requirements of one Licensed Practical Nurse per 25 residents during the day shift, a minimum of one LPN per 30 residents during the evening shift and a minimum of one LPN per 40 residents during the night shift. 4. Director of Nursing or Designee will conduct random audits to verify that LPN day shift, evening shift and night shift meet the requirements weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at the QAPI meeting for review and recommendations.