Failure to Meet Minimum LPN Staffing Requirements
Penalty
Summary
The facility failed to meet the required minimum staffing levels for Licensed Practical Nurses (LPNs) as mandated by regulation. Specifically, during the day shift, the facility did not provide at least one LPN per 25 residents for 14 out of the 21 days reviewed. The documented LPN staffing levels on these days were consistently below the required ratio based on the daily census, with several days showing a shortfall in the number of LPNs scheduled compared to what was required. Additionally, on the overnight shift, the facility did not meet the minimum requirement of one LPN per 40 residents for 20 out of the 21 days reviewed. The staffing records indicated that the number of LPNs present was frequently less than the required amount, with some nights having only one LPN when more were needed according to the resident census. These findings were confirmed during an interview with the Administrator, who acknowledged the discrepancies in LPN staffing levels during the specified review period.
Plan Of Correction
P5530 1. Findings of LPN nursing staff care ratios cannot be retroactively corrected. 2. Facility will provide a minimum of one Licensed Practical Nurse per 25 residents during the day shift and a minimum of one LPN per 40 residents during the night shift. Staffing team will meet daily Monday-Friday to review staffing needs and create plans to ensure LPN coverage. In order to recruit and retain staff, facility has an active nurse aide training course that runs continuously to hire and train new CNAs. Facility recently put up a recruitment billboard to attract nurses and CNAs. Facility also has active job ads and recruiters who work around the clock to interview and hire new staff. Facility continuously hosts staff morale events, staff spotlights, and monthly caught caring awards to retain current staff. The facility offers bonuses to current staff in an effort to schedule more staff per shift. 3. Scheduling manager will be educated on the requirements of one Licensed Practical Nurse per 25 residents during the day shift and a minimum of one LPN per 40 residents during the night shift. 4. Director of Nursing or Designee will conduct random audits to verify that LPN day shift and night shift meet the requirements weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at the QAPI meeting for review and recommendations.