LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required Licensed Practical Nurse (LPN) staffing ratios on multiple occasions between February 26, 2025, and March 2, 2025. Specifically, the facility did not provide the minimum number of LPNs per resident during the day, evening, and night shifts as mandated by the regulation effective July 1, 2023. On February 26, 2025, the facility had a census of 85 residents, requiring 3.40 LPNs during the day shift, but only 3.28 LPNs were available. Similarly, the evening shift required 2.83 LPNs, but only 2.68 were present. On February 28, 2025, with a census of 86 residents, the day shift required 3.44 LPNs, but only 3.12 were available, and the night shift required 2.15 LPNs, but only 1.96 were present. On March 2, 2025, the facility again failed to meet the staffing requirements with a census of 85 residents. The day shift required 3.40 LPNs, but only 3.02 were available, and the evening shift required 2.83 LPNs, but only 2.31 were present. Additionally, the night shift required 2.13 LPNs, but only 1.69 were available. The report notes that there were no additional higher-level staff available to compensate for these deficiencies. An interview with the Nursing Home Administrator confirmed the facility's failure to meet the required LPN-to-resident staffing ratios during the specified days.
Plan Of Correction
1. The facility cannot retroactively correct nursing staffing hours and ratios. 2. The facility is focusing on the retention of existing nursing staff and recruiting new staff through the efforts of the staffing committee and human resource department. 3. The Executive Director (ED) re-educated the scheduler and nursing supervisors on the staffing ratios and hours per patient day (HPPD). Staffing meetings to review the calculations for nursing staff ratios and HPPD for accuracy. 4. The ED or Designees to conduct Quality Improvement (QI) monitoring of daily schedules to ensure the ratio of care/minimum PPD will be met. QI monitoring conducted via OnShift Daily Schedules reviewed weekly x 4 weeks, then once a month as needed. Findings reported to the Quality Improvement Performance Improvement (QAPI) committee and updated as indicated. QI monitoring schedule modified based on findings.