LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required LPN-to-resident ratios on six shifts out of 48 reviewed, as evidenced by a review of nurse staffing records and staff interviews. Specifically, on December 21, 2024, the evening shift had 2.88 LPNs instead of the required 3.37 for a census of 101 residents. On December 22, 2024, the night shift had 2.38 LPNs instead of the required 2.53 for the same census. On December 25, 2024, the day shift had 3.19 LPNs instead of the required 4.16 for a census of 104, and the evening shift had 3.19 LPNs instead of the required 3.47. On December 30, 2024, the evening shift had 3.5 LPNs instead of the required 3.57 for a census of 107. Finally, on December 31, 2024, the night shift had 2.13 LPNs instead of the required 2.73 for a census of 109. The Nursing Home Administrator confirmed these deficiencies during an interview on January 3, 2025.
Plan Of Correction
The facility cannot retroactively correct the Licensed Practical Nurse Staff to resident ratios on past shifts identified. 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 comprehensive team approach. The facility utilizes contracted nursing staff, incentives, and flexible schedules, etc. 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 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.