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P5530

LPN Staffing Deficiency

Bryn Mawr, Pennsylvania Survey Completed on 03-06-2025

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 minimum staffing levels for Licensed Practical Nurses (LPNs) during both day and evening shifts over a period of 9 out of 21 days reviewed. Specifically, the regulation mandates a minimum of one LPN per 25 residents during the day shift and one LPN per 30 residents during the evening shift. However, the facility's staffing records revealed that on several occasions, the number of LPN hours provided was insufficient to meet these requirements. For instance, on February 14, 2025, the day shift had only 8 LPN hours for a census of 37 residents, whereas 11.84 hours were required. Similarly, on February 23, 2025, the evening shift had 8.50 LPN hours for a census of 62 residents, requiring 16.53 hours. The deficiency was confirmed through a review of nursing staff care hours and an interview with the facility's administrator, who acknowledged the shortfall in meeting the LPN-to-resident ratios. This issue was consistent across multiple days, indicating a pattern of inadequate staffing levels that did not comply with the regulatory requirements. The administrator's confirmation further substantiates the facility's failure to adhere to the mandated staffing ratios, impacting the quality of care provided to the residents.

Plan Of Correction

Nursing schedules were reviewed to ensure the proper LPN ratios on the day and evening shifts. NHA/designee will reeducate the scheduler Director of Nursing on the correct LPN ratio. NHA/designee will audit the nursing schedules in advance daily x4 weeks to ensure LPN's are being staffed at the proper ratio. Results will be shared at QA.

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