Failure to Maintain LPN Staffing Ratios
Penalty
Summary
The facility failed to maintain the required staffing ratios for Licensed Practical Nurses (LPNs) on five out of seven days reviewed, specifically on April 1, 2, 3, 4, and 5, 2025. The regulation mandates a minimum of one LPN per 25 residents during the day, one LPN per 30 residents during the evening, and one LPN per 40 residents overnight. On April 1 and 2, with a census of 99 residents, the facility did not meet the staffing ratios for all shifts. On April 3 and 4, with a census of 98 residents, the facility failed to meet the staffing ratios for the evening and overnight shifts. On April 5, with a census of 99 residents, the facility again did not meet the staffing ratios for all shifts. These deficiencies were identified through a review of nursing staff schedules and interviews with staff.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.