LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) on five specific days. On these days, the facility did not provide the minimum number of LPNs per residents as mandated by the regulation effective July 1, 2023. Specifically, the facility was short of LPN hours during the day, evening, and night shifts on March 24, 25, 26, 29, and April 11, 2025. The census data indicated that the number of residents required more LPNs than were scheduled, resulting in a deficiency in the required LPN care hours. The deficiency was confirmed through a review of nursing time schedules and staff interviews. On each of the identified days, the facility's census required a specific number of LPNs to meet the regulatory requirements, but the actual hours of LPN care provided fell short. The Nursing Home Administrator acknowledged the failure to meet the staffing requirements during an interview, confirming the deficiency in providing adequate LPN coverage as per the regulation.
Plan Of Correction
1. Staffing Coordinator will be educated on LPN staffing ratio requirements. 2. A scheduling app has been implemented for direct care staff and staff are acclimating to the procedures of applying for shifts and picking up open shifts/called off shifts. NHA is implementing recruitment focus meetings. 3. Facility conducts daily labor meetings attended by DON and NHA to manage direct care staff and monitor LPN ratios and track new applicants/new hires. 4. Staffing coordinator/designee to audit daily staffing sheet x 3 weeks to meet LPN ratio requirements. 5. Results to be submitted to QAPI for review and approval.