LPN Staffing Deficiency 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 during the night shift on three specific days within a two-week period. The nursing time schedules from December 12, 2024, to December 25, 2024, revealed that on December 19, 24, and 25, the facility did not have the required number of LPNs on duty. Specifically, on December 19, with a census of 212 residents, only 4.67 LPNs were present when 5.30 were required. On December 24, with a census of 206 residents, 4.70 LPNs were present when 5.15 were required. On December 25, with a census of 207 residents, 5.10 LPNs were present when 5.18 were required. The Nursing Home Administrator and Director of Nursing confirmed this staffing deficiency during an interview on December 26, 2024, acknowledging the lack of additional higher-level staff to compensate for the shortage.
Plan Of Correction
A follow-up review was completed on 12/27/2024 for LPN ratio numbers. 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, extra day pay. 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. There were no negative outcomes to residents. The facility will continue to ensure the schedule reflects the required staffing ratios and address call offs. An off-shift scheduler was hired to perform scheduling duties after hours to maintain ratio. Re-education will be conducted by the NHA/designee to the new Human Resource Director on calculating Ratios. Staff and supplemental staffing have been reminded of the importance of them reporting to work as assigned. A weekend Manager program is being 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.