Failure to Maintain Required LPN Staffing Ratios
Penalty
Summary
The facility failed to maintain the required staffing ratios for Licensed Practical Nurses (LPNs) on six out of 21 days reviewed. Specifically, the facility did not meet the mandated LPN-to-resident ratios during the day, evening, and overnight shifts on July 2 and 6, 2024, and November 25, 26, 27, and 28, 2025. The deficiency was identified through a review of nursing staff schedules, punch reports, and interviews with staff. On July 2, 2024, the facility had a census of 80 residents, requiring 25.00 hours of LPN care during the day shift, but only 24.00 hours were provided. On July 6, 2024, with a census of 77 residents, the facility required 15.40 hours of LPN care during the evening shift, but only 8.00 hours were provided. On November 25, 2024, with a census of 73 residents, 23.36 hours of LPN care were needed during the day shift, but only 15.00 hours were provided. On November 26, 2024, with a census of 72 residents, 23.04 hours were required, but only 22.00 hours were provided. On November 27, 2024, again with a census of 72 residents, 23.04 hours were needed, but only 16.00 hours were provided.
Plan Of Correction
1. Facility to ensure that LPN ratios are maintained in accordance with regulatory requirements. 2. Staffing Coordinator or designee will conduct an audit of staffing schedules from 2/22/25-2/28/25 to verify LPN ratios each shift. If discrepancies are identified, regulatory requirements will be reviewed by the Nursing Home Administrator and Staffing Coordinator. 3. Nursing Home Administrator or designee will reeducate Staffing Coordinator on the Department of Health's Guidance for Calculating Staff to Resident Ratios and Direct Nursing Care Hours by 3/4/25. 4. Staffing Coordinator or designee will conduct audits 2 days per week involving all three shifts for 4 weeks, and then 2 days per month involving all three shifts for 2 months to ensure that nurse aide ratios are consistent with regulatory requirements. The results of these audits will be forwarded to the Quality Assurance Process Improvement team for review and recommendations.