Failure to Meet LPN to Resident Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios as mandated by regulations effective July 1, 2023. Specifically, the facility did not maintain the minimum ratio of one LPN per 25 residents during the day shift from 7:00 a.m. to 3:00 p.m. on nine out of the fourteen days reviewed. The days in question were December 27, 28, 29, and 30, 2024, and January 1, 2, 13, 14, and 15, 2025. This deficiency was identified through a review of nursing schedules and staff interviews, indicating a consistent shortfall in staffing levels during the specified period.
Plan Of Correction
1) Facility cannot retroactively correct. 2) NHA/designee will review LPN staffing ratios for the last 4 weeks to ensure compliance and adherence to regulation. 3) NHA/Designee will re-educate staff scheduler and DON on regulation of LPN staffing ratios to ensure ongoing compliance. Facility will conduct daily staffing meeting to review LPN ratios to ensure ongoing compliance and systematic change. 4) NHA/Designee will conduct audit of projected LPN ratios. Audit will be conducted 2x a week x 4 weeks, then 1x a week x 4 weeks, then 2x a month x 2 months, then 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.