(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 a review of nursing time schedules, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratio for 20 of 21 days reviewed.
Findings include:
Review of nursing schedules for 21 days from February 8 through February 28, 2024, revealed the following:
The facility failed to meet the minimum LPN to resident ratio of one LPN for 25 residents on day shift (7:00 a.m. to 3:00 p.m.) on February 11, 14, 18, 23, 24, 25, and 27, 2024.
The facility failed to meet the minimum LPN to resident ratio of one LPN for 30 residents on evening shift (3:00 p.m. to 11:00 p.m.) on February 8, 10, 12, 13, 14, 16, 18, 19, 24, 25, 26, and 27, 2024.
The facility failed to meet the minimum LPN susbstitute regulation for a replacement for an RN with a census under 59 on the night shift on February 9, 10, 14, 17, 18, 19, 20, 21, 24, 25, 26, 27, and 28, 2024.
During an interview on February 29, at 12:30 p.m., the Administrator confirmed that the facility did not meet the minimum required nursing staff to resident ratio on the days identified.
| | Plan of Correction - To be completed: 06/15/2024
1. The facility is unable to retroactively provide minimum LPN ratio for 3/6/2024.
2. An audit was completed to ensure ratios were met. Facility is putting an emphasis on recruitment to increase LPN staff by having a strong sign on bonuses and competitive wages with surrounding areas. Agency to assist with staffing ratios while hiring. Facility started using Dropstat for scheduling to keep better track of the staffing needs and make it easier for staff to know what shifts are open to pick up with in-house and agency staff to minimize the staffing difficulties.
3. The DON and recruitment were educated on the new Dropstat scheduling platform to meet assist with increasing staffing ratios.
4. The DON or designee will conduct an audit of the nursing care ratios to ensure it is provided weekly X4 weeks then monthly X2 months. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.
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