LPN Staffing Shortage on Night Shift
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) during the night shift on March 15, 2025. Specifically, the facility did not provide the minimum of one LPN per 40 residents, as mandated by the regulation effective July 1, 2023. A review of the nursing time schedules and facility census data from March 11 to March 15, 2025, revealed a staffing shortage on the night of March 15, 2025, when the census was 92 residents, but the actual LPN hours provided were insufficient. This deficiency was confirmed during an interview with the Nursing Home Administrator on March 19, 2025.
Plan Of Correction
The facility cannot retroactively correct cited deficiencies. The facility will continue to maintain the required ratios and implement a contingency plan if needed by calling in off duty staff, calling sister facilities or utilizing bonuses as needed to ensure sufficient nursing staff. Additionally, the facility will continue to maintain efforts to recruit and retain staff to meet care needs and ensure residents are receiving appropriate care and services. The regional staff educated NHA/DON on ensuring sufficient nursing staff to meet residents' needs and ensure that the facility is holding daily staffing meetings. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 5x weekly for 4 weeks, then monthly for 2 months to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.