LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required LPN-to-resident staffing ratios on multiple occasions during the review period from December 8, 2024, to January 11, 2025. Specifically, the facility did not provide the minimum number of LPNs needed for the day shift on three days, the evening shift on one day, and the night shift on four days. For instance, on December 11, 2024, the facility's census required 5.20 LPNs during the day shift, but only 5.03 LPNs were available. Similarly, on December 25, 2024, the day shift required 5.08 LPNs, but only 4.88 LPNs were present. These discrepancies were confirmed through a review of nursing schedules, staffing information, and staff interviews. The deficiency was further highlighted by the lack of additional higher-level staff to compensate for the shortfall in LPNs. On December 9, 2024, the night shift required 3.10 LPNs, but only 2.22 LPNs were available. On December 23, 2024, the night shift required 3.15 LPNs, but only 2.56 LPNs were present. The Nursing Home Administrator confirmed on January 17, 2025, that the facility did not meet the required staffing ratios on the specified days, indicating a systemic issue in maintaining adequate staffing levels to meet regulatory requirements.
Plan Of Correction
1. The ratios noted in the survey findings cannot be corrected as this is a past event. 2. Calculation of shift ratios will be completed and reviewed daily for accuracy by the scheduler or designee. 3. The facility has developed internal incentives to retain and attract staff and meet shift ratio requirements. Administrator will re-educate Director of Nursing and Scheduler regarding staffing ratios regulations. Facility scheduler, Director of Nursing, Human Resources, and Administrator have a daily staffing meeting (5 days per week) to review schedules including compliance with ratios. For staff call offs, every effort will be made to replace the call off using resources available including communicating with staff to replace the vacancy. Staffing patterns are projected at least one week in advance to enable ongoing efforts to fill any vacant shifts. The facility will take admissions when staffing is appropriate. 4. Ratios will be monitored daily by Scheduler and/or Director of Nursing or designee. Audits of ratios will be completed by Director of Nursing or designee daily for 4 weeks then 3 days per week x 2 months or until substantial compliance is achieved. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee.