LPN Staffing Deficiency on Day Shift
Penalty
Summary
The facility failed to meet the required minimum staffing levels for Licensed Practical Nurses (LPNs) during the day shift on one occasion. Specifically, on January 11, 2025, the facility did not provide the mandated ratio of one LPN per 25 residents, as evidenced by staffing records showing only 3.40 LPNs available for a resident census of 108, where 4.32 LPNs were required. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 28, 2025.
Plan Of Correction
The facility cannot retroactively correct the Licensed Practical Nurse staff to resident ratios on previous shifts. The NHA/Designee educated the Nursing Staff Scheduler and Director of Nursing on minimum Licensed Practical Nurse staff to resident ratios on all shifts, ensuring continued proactive planning and follow-up to address issues identified. Daily staffing meetings will be held with the NHA, Staff Scheduler, DON, and other team members as necessary to review per patient hours 5 days per week to review projected staffing, reconcile prior days staffing, and follow up as needed for continued improvement and a comprehensive team approach. The facility utilizes contracted nursing staff, incentives, and flexible schedules for current staff, focuses on recruitment of direct hire staff for continuity of care, as well as employee engagement, feedback through town hall meetings, and individualized support to decrease absences. A call-in list is used to attempt to fill unexpected absences. Resident occupancy is reviewed and revised as needed with the IDT during staffing meetings. The NHA/Designee will quality monitor Licensed Practical Nurse staff to resident ratios 5 days per week for 4 weeks, then one per week for 3 weeks, then monthly for 2 months to ensure minimum Licensed Practical Nurse to resident ratios are met. The NHA/Designee will quality monitor daily staffing meetings 5 days per week for 4 weeks, weekly for 3 weeks, then monthly for 2 months to ensure staffing meetings are occurring with required attendees.