LPN Staffing Deficiency on Evening and Night Shifts
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) on specific shifts, as mandated by the regulation effective July 1, 2023. On two occasions during the evening shift, the facility did not provide the minimum of one LPN per 30 residents, specifically on 2/27/25 and 3/1/25. Additionally, on the night shift of 2/28/25, the facility did not meet the requirement of one LPN per 40 residents. The review of nursing time schedules and facility census data from 2/25/25 through 3/2/25 confirmed these staffing shortages. The Nursing Home Administrator acknowledged the failure to meet the staffing requirements during an interview conducted on 3/4/25.
Plan Of Correction
The facility cannot retroactively correct cited deficiencies. The facility will continue to maintain the required LPN ratios and implement a contingency plan if needed by calling in off duty LPN staff, calling sister facilities or utilizing agency as needed to ensure sufficient Cart nurse staff meets PA Regulation. The RDO re-educated NHA/DON on ensuring sufficient nursing staff. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 5x per week for x4 weeks; then Weekly x2 Months and then Monthly x 2 months; to ensure LPN ratios are met. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.