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P5530

LPN Staffing Deficiencies in Facility

New Castle, Pennsylvania Survey Completed on 12-13-2024

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) as mandated by regulations effective July 1, 2023. Specifically, the facility did not maintain the minimum ratio of one LPN per 25 residents during the day shift on one occasion and failed to meet the minimum ratio of one LPN per 40 residents on the overnight shift on eight occasions. The review of staffing documents revealed that on December 7, 2024, with a census of 89 residents, only 3.0 LPNs were on duty when 3.56 were required. Additionally, during the overnight shifts on multiple dates, the facility census ranged from 88 to 90 residents, but only 2.0 LPNs were on duty when between 2.20 and 2.25 were required. The Nursing Home Administrator confirmed these staffing deficiencies during an interview.

Plan Of Correction

Facility Staffing Coordinator was reeducated on current LPN staffing ratios according to current census and shifts. Facility will attempt to utilize facility staff and temporary staffing agencies as needed. Facility weekly Schedule will be made in accordance with current Pennsylvania DOH Staffing guidelines and facility census. Nursing Supervisors to be in-serviced on staffing guidelines by 1/8/2025. For the shifts on the dates indicated, all residents in the facility received the care that they required, and the facility received no complaints from residents, their responsible person(s), or employees. Schedule and census will be monitored daily per shift by RN Nursing Supervisor for call offs and changes in census. Adjustments will be made as needed by Director of Nursing, RN Nursing Supervisor, or Staffing Coordinator. Facility will utilize facility staff and/or temporary Staffing Agencies to fill in shifts as needed according to type of nursing service personnel that is needed. Assistant Administrator or designee will monitor schedules at least weekly x 4 weeks and then every 2 weeks until deemed in compliance by facility QAPI Committee.

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