(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 time schedules and staff interviews, it was determined that the facility failed to provide a minimum of one licensed practical nurse (LPN) per 40 residents overnight on five of seven days reviewed (February 15, 2024, February 16, 2024, February 17, 2024, February 18, 2024 and February 21, 2024).
Findings include:
Review of facility census data indicated that on February 15, 2024, the facility census was 35, which required 1 LPNs during the night shift.
Review of the nursing time schedules and time punch card documentation revealed 0 LPNs provided care on the nightshift on February 15, 2024. No additional excess higher-level staff were available to compensate this deficiency.
Review of facility census data indicated that on February 16, 2024, the facility census was 35, which required 1 LPN during the night shift.
Review of the nursing time schedules and time punch documentation revealed 0 LPNs worked on the night shift on February 16, 2024. No additional excess higher-level staff were available to compensate this deficiency.
Review of facility census data indicated that on January 17, 2024, the facility census was 33, which required 1 LPN on the nightshift.
Review of the nursing time schedules and time punch card documentation revealed 0 LPNs provided care on the nightshift on February 17, 2024. No additional excess higher-level staff were available to compensate this deficiency.
Review of facility census data indicated that on February 18, 2024, the facility census was 33, which required 1 LPN during the nightshift.
Review of the nursing time schedules and time punch documentation revealed 0 LPNs worked on the night shift on February 18,2024.
No additional excess higher-level staff were available to compensate this deficiency.
Review of facility census data indicated that on February 21, 2024, the facility census was 34, which required 1 LPN on the nightshift.
Review of the nursing time schedules and time punch documentation revealed 0 LPNs worked on the night shift on February 21, 2024. No additional excess higher-level staff were available to compensate this deficiency.
An interview February 22, 2024, at 2 PM the Nursing Home Administrator confirmed that the facility did not meet the state minimum nursing ratios for LPNs. The NHA stated that the LPN on duty on the night shift was substituted for an RN as the facility census was under 59 residents, but no additional LPN was scheduled to provide the required LPN hours to meet the ratio.
| | Plan of Correction - To be completed: 03/05/2024
1. The Facility cannot retroactively correct the staffing hours on the cited dates. A review of the Residents on those dates demonstrated there were no negative outcomes experience by the Residents related to staffing.
2. The facility cannot retroactively correct past nurse staffing issues. Moving forward the Facility will continue to schedule staff in accordance with the mandated requirements and make a good faith effort to utilize internal and external resources in the event of unforeseen staffing requirement deficits
3. To prevent reoccurrence, the CQS/designee will educate the DON and NHA on the importance of staffing the facility according to regulations and policy.
4. To monitor and maintain on-going compliance, The NHA/designee will audit the direct care staffing ratios weekly times 4 weeks, then monthly times 2 months to ensure regulatory compliance, results of the audits will be forwarded to the QAPI committee.
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