Failure to Meet Minimum LPN Staffing Ratios on Multiple Shifts
Penalty
Summary
The facility failed to meet the required minimum staffing ratios for Licensed Practical Nurses (LPNs) on both day and night shifts for 15 out of 63 reviewed shifts. Specifically, on multiple dates, the number of LPNs scheduled for the day shift did not meet the mandated ratio of 1 LPN per 25 residents, with actual staffing falling short of the required number based on the facility's census. Similarly, on several night shifts, the facility did not provide the required 1 LPN per 40 residents, again resulting in fewer LPNs than necessary according to the census. Staffing records confirmed these deficiencies, and it was noted that no additional higher-level staff were present to compensate for the shortfall in LPN coverage on the affected shifts. An interview with the Director of Nursing corroborated that the facility did not meet the required LPN-to-resident ratios on the specified dates. The report does not mention any specific residents affected or detail any medical conditions or outcomes related to the staffing deficiencies.
Plan Of Correction
The facility cannot correct the LPN staffing hours on the cited dates; however, efforts are continuously being made to maintain the staffing hours within regulatory guidelines. Moving forward, the facility will make good faith efforts by continuing to recruit staff through participation in job fairs, offering sign-on and referral bonuses, and utilizing internal/external resources in the event of staffing requirement deficits. RDCS will re-educate the NHA, Nursing Administration, RN Supervisors, Scheduler, and HR/Payroll staff on PA staffing ratio requirements. To monitor and maintain ongoing compliance, the NHA/designee will audit the LPN staffing ratios weekly for four weeks, and then monthly for two months. The audit outcomes will be presented to the QAPI Committee for further review and recommendations.