Failure to Meet Minimum LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum LPN-to-resident staffing ratios on 19 out of 63 reviewed shifts. According to the reviewed weekly staffing records, the facility did not provide the mandated number of LPNs per residents on several night and evening shifts, with specific shortfalls noted for each date and census size. The required ratios were 1 LPN per 25 residents during the day, 1 per 30 in the evening, and 1 per 40 overnight, but the actual staffing fell below these thresholds on multiple occasions. No additional higher-level staff were present to compensate for the LPN shortfalls on the affected shifts. The Director of Nursing confirmed during an interview that the facility had not met the required LPN-to-resident ratios on the specified dates. The report does not mention any specific residents affected or provide details about their medical history or condition at the time of the deficiency.
Plan Of Correction
Step 1. The facility cannot retroactively provide the minimum number of LPN hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated LPN ratio hours. The facility is actively recruiting LPNs and offering a sign-on bonus to new employees and referral bonuses to current employees. The facility has posted the job on multiple recruiting sites. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON, and Scheduler on the updated staffing regulations in relation to the minimum staffing of LPNs for the facility. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum LPN hours needed for the facility. Audits will be completed 5x/week for 4 weeks, and then weekly for 2 months. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations. P 5530