Failure to Meet Minimum LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum staffing ratios for Licensed Practical Nurses (LPNs) across multiple shifts and days, as mandated by regulation effective July 1, 2023. Specifically, the facility did not provide the required number of LPNs per resident on the day shift for 11 out of 21 days reviewed, on the evening shift for one day, and on the overnight shift for four days. Staffing documents showed that on these dates, the number of LPNs scheduled and worked was consistently below the calculated requirement based on the facility's census for each shift. The deficiency was confirmed through a review of nursing staffing documents and an interview with the Nursing Home Administrator, who acknowledged the shortfalls. The report details the specific census numbers and the corresponding LPN staffing levels for each deficient shift, demonstrating that the facility did not meet the mandated LPN-to-resident ratios on multiple occasions during the review period.
Plan Of Correction
The facility will provide staff to ensure the needs of residents are met. The facility will produce a daily schedule to meet the required licensed practical nurse to resident ratios on all shifts. The Director of Nursing or designee will provide re-education on minimum licensed practical nurse staffing ratios to Registered Nurse Supervisors and Human Resources/Scheduling, who are responsible for maintaining adequate staffing and licensed practical nurse staffing ratios. The Director of Nursing or designee will educate HR/Scheduler and RN supervisors on protocols for replacing staff related to call-offs, including mandating staff when replacement staff are unable to be found. The Director of Nursing or designee will meet 5 days per week for 4 weeks to audit the daily deployment sheet for accuracy to ensure the daily schedule meets licensed practical nurse ratio. The Director of Nursing or designee will audit the hours worked to ensure that the minimum number of licensed practical nurse staff to resident ratios have been met, using the Department of Health staffing grid for 4 weeks. The Director of Nursing or designee will audit weekly that protocols were followed when a call-off occurred. This includes asking staff to stay, posting need, posting need with agencies, offering bonus, and mandating when needed. The facility has ads posted on Indeed and has recently advertised our shift differential for licensed practical nurses on second and third shifts, with an increase in applications over the last two weeks. The results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.