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P5530

LPN Staffing Shortage on Night Shift

Brackenridge, Pennsylvania Survey Completed on 12-19-2024

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) during the night shift on December 14, 2024. According to the nursing time schedules reviewed for the period from December 1, 2024, to December 18, 2024, the facility did not provide the minimum of one LPN per 40 residents, as mandated by the regulation effective July 1, 2023. On the night of December 14, 2024, the facility had a census of 86 residents, requiring 3.44 LPNs, but only 3.04 LPNs were present. This staffing shortage was confirmed by the Nursing Home Administrator during an interview on December 19, 2024, at 2:00 p.m., who acknowledged the failure to meet the staffing requirement without any additional higher-level staff to compensate for the deficiency.

Plan Of Correction

There were no adverse effects to the residents of our facility as a result of decreased licensed nurse staffing ratios on 12/14/24. The Director of Nursing, Human Resources, and the Scheduler will be re-educated on new July 1 licensed nurse to resident ratios by the Nursing Home Administrator or Designee. Staffing meetings will be held 3 days a week to review the licensed nursing staff ratios for the previous and current day, as well as the upcoming week to ensure appropriate staffing levels. If projected staffing levels are below the state mandated ratios, then the facility will reach out to current staff and to the staffing agencies to enlist staff to meet the minimum requirement. The facility will continue to recruit nursing staff through all platforms as well as utilize bonus structures and outside agencies. Audits of licensed nursing staff ratios will be completed weekly x4 by the NHA/designee to ensure licensed staff ratios meet the state minimums. Results of the audits will be reported to our QAPI committee monthly for review and recommendations.

See complete original report
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