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P5530

LPN Staffing Shortages Across Shifts

Mercer, Pennsylvania Survey Completed on 01-24-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) as mandated by regulations effective July 1, 2023. Specifically, the facility did not maintain the minimum LPN-to-resident ratios on several occasions across different shifts. On the day shift, the facility was short of the required LPNs on one out of 21 days reviewed, with a census of 42 residents requiring 1.68 LPNs, but only 1.00 LPN was present. The evening shift experienced shortages on three days, with the facility failing to meet the required LPN ratio for resident counts ranging from 42 to 44. The overnight shift was particularly affected, with shortages on 20 out of 21 days reviewed, where the facility consistently had only 1.00 LPN working despite needing between 1.05 and 1.13 LPNs based on the resident census. The deficiencies were confirmed through a review of the facility's nursing staffing documents and an interview with the Nursing Home Administrator. The administrator acknowledged the failure to meet the minimum LPN ratio requirements on the specified shifts and dates. This consistent shortfall in staffing indicates a systemic issue in maintaining adequate nursing coverage, which is crucial for ensuring the safety and well-being of the residents.

Plan Of Correction

1. The facility was unable to make corrective action for the (Licensed Practical Nurse ratio) for identified days that have already passed. All residents received care in accordance with their care plans and physician orders. 2. Director of Nursing or designee will re-educate the Labor Manager and the RN Supervisors on the 7/1/2024 Licensed Practical Nurse ratio requirements. 3. Facility continues to offer incentives, competitive wages, and several other benefits in an effort to hire for all open positions. 4. Nursing Home Administrator, Director of Nursing, and Labor Manager will conduct daily staffing meetings Monday - Friday to review (Licensed Practical Nurse ratios) throughout the day, the following day, and the weekend. In the event of vacancies the Labor Manager or designee will follow staffing policies including offering open shifts to internal staff, contracted agency staff, and offering current staff to stay extra or start earlier. 5. Director of Nursing or designee will audit daily staffing ratios along with all steps taken to fill vacancies 5 days a week and ongoing. 6. Results of the audits will be reviewed and recorded in the monthly Quality Assurance Performance Improvement meeting.

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