Failure to Meet Minimum LPN Staffing Requirements on Night Shift
Penalty
Summary
Facility administrative staff failed to provide the required minimum number of licensed practical nurses (LPNs) during the night shift on one of ten reviewed days. Specifically, on the night in question, the facility census was 104 residents, which required 20.80 LPN hours, but only 16.00 LPN hours were provided. This deficiency was identified through a review of nursing time schedules and census data, and was confirmed by the Nursing Home Administrator during an interview. No information regarding the medical history or condition of specific residents was provided in the report.
Plan Of Correction
The facility will ensure state-required LPN ratios are met during the overnight shift. The facility cannot correct that LPN staffing ratios of 1:40 were not met on the overnight shift on 8-10-25. The facility will ensure that the LPN staffing ratio of 1:40 is met during the overnight shift. Open positions will continue to be posted on various platforms. We will continue with a weekly retention and recruitment meeting. We have help wanted signs on our property. We posted an ad in our local township summer 2025 newsletter that gets distributed to over 3000 homes and businesses in our township. We offer a sign-on bonus and bonuses as incentives to pick up shifts. We offer a "Refer a Friend" bonus to our staff. We utilize staffing agencies to fill needed shifts. We will continue to review referrals to ensure we can meet their needs prior to accepting. The Nursing Home Administrator will re-educate the Director of Nursing, HR Director/Scheduler, and RN Supervisors on regulation P5530 and ensuring LPN staffing ratios are met during the overnight shift. Staffing ratios will be reviewed at our daily staffing meeting to ensure ratios are scheduled to be met. The RN Nursing Supervisors will continue to review shift staffing ratios on evenings and weekends. If the facility's projections to meet LPN ratios on the overnight shift fall below required ratios due to call-offs, no call no-shows, etc., the RN Supervisors will be responsible to ask currently working staff to pick up a shift, call off-duty personnel, and/or call extra support staff via staffing agencies to assist as necessary. The HR Director/designee will audit staffing sheets daily for three months to ensure LPN staffing ratios are being met during the overnight shift. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits. Date of compliance: 9-16-2025