LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios as mandated by regulations effective July 1, 2023. Specifically, during the day shift, the facility did not provide the minimum of one LPN per 25 residents on two occasions within the 21 days reviewed. On December 27, 2024, there were 4.5 LPNs for a census of 113 residents, requiring 4.52 LPNs, and on December 29, 2024, there were 4 LPNs for a census of 111 residents, requiring 4.44 LPNs. Additionally, the night shift was understaffed on six occasions, failing to provide the required one LPN per 40 residents. For instance, on December 4, 2024, there were 2.19 LPNs for a census of 116 residents, requiring 2.90 LPNs, and similar shortfalls were noted on December 7, 18, 21, 26, and 30, 2024. These deficiencies were confirmed through an interview with the Nursing Home Administrator and Director of Nursing on January 2, 2025.
Plan Of Correction
1. Facility will continue to take measures to adequately provide staff to ensure the needs of residents are met. 2. The Director of Nursing or designee will provide re-education on minimum staffing ratios to RN Supervisors, Human Resources, and Scheduling Coordinator who are responsible to maintain adequate staffing and staffing ratios. 3. The Director of Nursing or designee will audit the daily schedules to ensure the minimum number of staff to resident ratios have been scheduled and will audit that protocols were followed if a call off occurred. 4. Audits will be completed weekly, and results of these audits will be reviewed at Quality Assurance and Process Improvement Meetings until substantial compliance is achieved. 5. Compliance Date: 1/27/2025