LPN Staffing Deficiencies
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) across various shifts over a 21-day period. Specifically, the facility did not provide the minimum number of LPNs per resident during the day, evening, and night shifts on multiple occasions. For the day shift, the facility was short of the required LPNs on 13 out of 21 days, with the census ranging from 62 to 65 residents, necessitating between 2.48 to 2.60 LPNs. However, the facility only provided between 2.00 to 2.13 LPNs, with no additional higher-level staff available to compensate for the deficiency. Similarly, during the evening shift, the facility was understaffed on 7 out of 21 days, with the census requiring between 2.07 to 2.17 LPNs, but only 1.56 to 2.00 LPNs were provided. The night shift also experienced staffing shortages on 13 out of 21 days, with the census requiring between 1.55 to 1.60 LPNs, but only 0.25 to 1.25 LPNs were available. These staffing deficiencies were identified through a review of the facility's census data, nursing time schedules, and deployment sheets, indicating a consistent failure to meet the regulatory requirements for LPN staffing levels during the specified period.
Plan Of Correction
1. The facility cannot correct that the facility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift for 13 of 21 days (12/29/24, 1/3, 1/4/25, 1/5, 1/7, 1/8, 1/9, 1/12, 1/13, 1/14, 1/15, 1/16, and 1/18/25), one LPN per 30 residents on the evening shift for 7 of 21 days (12/30/24, 1/5, 1/6, 1/12, 1/14, 1/16, and 1/18/25) and one LPN per 40 residents on the night shift for 13 of 21 days (12/29, 12/30, and 12/31/24, 1/1, 1/2/25, 1/5, 1/6, 1/9, 1/10, 1/11, 1/14, 1/16, and 1/18/25). 2. The facility will ensure that LPN staffing ratios are met every shift. 3. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5530 and ensuring LPN staffing ratios are met each shift. Daily shift staffing ratios will be reviewed at daily staffing meetings. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist. 4. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure LPN staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.