(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
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Observations:
Based on review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one licensed practical nurse per 25 residents during the day shift for two of 21 days reviewed; and one licensed practical nurse per 30 residents during the evening shift for one of 21 days reviewed; and one licensed practical nurse per 40 residents during the night shift for nine of 21 days reviewed.
Findings include:
Review of nursing staff care hours provided by the facility revealed the following licensed practical nurse (LPN) scheduled for the following resident census:
Day shift: January 29, 2024, 3.01 LPNs for a census of 88; requires 3.52 LPNs. January 30, 2024, 3.10 LPNs for a census of 88; requires 3.52 LPNs
Evening shift: February 3, 2024, 2.79 LPNs for a census of 89; requires 2.97 LPNs.
Night shift: January 28, 2024, 1.89 LPNs for a census of 88; requires 2.20 LPNs. January 29, 2024, 1.78 LPNs for a census of 88; requires 2.20 LPNs. January 30, 2024, 2.10 LPNs for a census of 88; requires 2.20 LPNs. January 31, 2024, 1.64 LPNs for a census of 88; requires 2.20 LPNs. February 1, 2024, 1.70 LPNs for a census of 90; requires 2.25 LPNs. February 3, 2024, 2.09 LPNs for a census of 89; requires 2.23 LPNs. March 3, 2024, 1.76 LPNs for a census of 81; requires 2.03 LPNs. March 10, 2024, 1.75 LPNs for a census of 78; requires 1.95 LPNs. March 12, 2024, 1.68 LPNs for a census of 79; requires 1.98 LPNs.
The Director of Nursing was notified via phone of the above findings on 3/14/24 at 12:38 PM.
| | Plan of Correction - To be completed: 04/26/2024
A review of the staffing schedules will be conducted to ensure compliance with the ratio of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening and 1 LPN per 40 residents overnight.
An in service will be conducted with the Scheduler to ensure compliance with the ratio of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening and 1 LPN per 40 residents overnight.
An audit will be conducted weekly of the next 4 weeks of nursing schedules to ensure compliance with the ratio of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening and 1 LPN per 40 residents overnight. Facility will be in compliance with Department's revised guidance for staffing ratios that will allow use of mathematical calculations when implemented.
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