LPN Staffing Deficiency on Evening Shifts
Penalty
Summary
The facility failed to meet the required LPN-to-resident staffing ratios on two occasions during the evening shift between December 8 and 28, 2024. On December 20, 2024, the facility had a census of 72 residents, necessitating 2.40 LPNs, but only 2.14 LPNs were available. Similarly, on December 28, 2024, with a census of 65 residents requiring 2.17 LPNs, only 2.13 LPNs were present. The facility did not have additional higher-level staff to compensate for these deficiencies. This was confirmed in an interview with the Nursing Home Administrator on December 30, 2024.
Plan Of Correction
The facility will continue to take measures to adequately provide staff to ensure the needs of residents are met. The facility will continue to take measures to adequately provide staff to meet the required Licensed Practical Nurse to resident ratios on the day shift. The Director of Nursing or designee will provide re-education on minimum staffing ratios to Registered Nurse Supervisors, Human Resources, and Scheduling who are responsible to maintain adequate staffing and staffing ratios. The Director of Nursing or designee will re-educate Human Resources, Scheduler and Registered Nurse supervisors of protocols for calling in staff related to call offs. The Director of Nursing or designee will audit the daily schedules to ensure that the minimum number of staff to resident ratios have been scheduled and will audit that protocols were followed after a call off occurred. These audits will be conducted weekly, and the results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.