LPN Staffing Deficiency Across Multiple Shifts
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) across multiple shifts, as evidenced by a review of nursing staffing hours and staff interviews. Specifically, the facility did not ensure a minimum of one LPN per 25 residents on eight of 21 day shifts reviewed, one LPN per 30 residents on eight of 21 evening shifts reviewed, and one LPN per 40 residents on three of 21 overnight shifts reviewed. This deficiency was identified during specific periods, including October 13 to 19, 2024, December 29, 2024, through January 4, 2025, and February 28, 2025, through March 6, 2025. The findings revealed that on several occasions, the number of LPNs scheduled was insufficient for the resident census. For instance, on October 18, 2024, there were 3.03 LPNs scheduled for a census of 76 residents, whereas 3.04 LPNs were required. Similar shortfalls were noted on other dates, such as December 29, 2024, and January 1, 2025, where the number of LPNs scheduled did not meet the required staffing levels. These discrepancies in staffing levels were consistent across day, evening, and overnight shifts, indicating a systemic issue in maintaining the mandated LPN-to-resident ratios.
Plan Of Correction
1. Nursing Staff care hours will be reviewed daily for the current day and for the remainder of the week during morning meeting for compliance with current regulations of a minimum of 1 LPN for 25 Residents during the day, 1 LPN per 30 Residents during the evening shift and 1 LPN per 40 Residents on overnight shift. 2. Will continue to actively hire and advertise open positions to meet current regulations. 3. The facility will continue to use per diem staff to fill in open shifts and ask current LPNs, and RNs to fill in open LPN shifts. 4. DON/designee will complete weekly audits on LPN staffing ratio for four weeks and then monthly for three months and bring to the monthly QA meeting for review.