Insufficient LPN Staffing on Night Shift
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of one licensed practical nurse (LPN) per 40 residents on the night shift for two specific days. On January 25 and January 26, 2025, the facility's nursing schedules and census information revealed that the number of LPNs on duty was insufficient for the resident census. Specifically, on January 25, the facility had 30.50 LPNs when 39.56 were needed for a census of 211 residents. Similarly, on January 26, there were 31.25 LPNs available when 39 were required for a census of 208 residents. This deficiency was confirmed during an interview with the Director of Nursing on January 30, 2025.
Plan Of Correction
The Center continues to have retention and recruitment activities in place. Nursing leadership did all things reasonably possible to meet the required ratios through bonuses, day off on another day, split shifts, etc. All unscheduled staff were contacted, and supplemental staffing were contacted to send replacement staff. Ancillary staff were available and assisted in various tasks such as call bell attendant, delivery and removal of meal trays, delivery of water, bed making, and performance of other tasks within their scope of practice. The facility will continue to ensure the schedule reflects the required staffing ratios and address call-offs. LPN students are doing their clinical rotations on-site in efforts to recruit for employment. An off-shift scheduler was hired to perform scheduling duties after hours to maintain ratio. Employment advertisement will be placed in our local newspaper of the opportunities at the Center. Staff and supplemental staffing have been reminded of the importance of them reporting to work as assigned. A weekend Manager program has been implemented, which will add extra monitoring on the weekends. No residents were affected. To monitor and maintain ongoing compliance, the DON/designee will audit 5 staffing sheets x 4 Weeks to ensure LPN night shift ratios are being met. Audit results will be reviewed with QAPI Committee meeting monthly to determine the need for further audits.