(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 staffing documents and staff interview, it was determined that the facility failed to ensure a required minimum of one licensed practical nurse (LPN) per 25 residents on day shift for two of 11 day shifts reviewed (June 8 and 9, 2024); and one LPN per 40 residents on the overnight shift for one of 11 night shifts reviewed (June 12, 2024).
Findings Include:
Review of facility-provided staffing ratio information for June 8, 2024, on day shift, revealed a census of 168 residents. Further review revealed an LPN ratio of 5; therefore, the facility did not meet the required minimum LPN ratio for the facility census on that shift.
Review of facility-provided staffing ratio information for June 9, 2024, on day shift, revealed a census of 170 residents. Further review revealed an LPN ratio of 5; therefore, the facility did not meet the required minimum LPN ratio for the facility census on that shift.
Review of facility-provided staffing ratio information for June 12, 2024, on the overnight shift, revealed a census of 168 residents. Further review revealed an LPN ratio of 3; therefore, the facility did not meet the required minimum LPN ratio for the facility census on that shift.
During an interview with the Director of Nursing on June 13, 2024, at 1:00 PM, she was made aware that the LPN ratios failed to meet the staffing regulations. No additional information was provided.
| | Plan of Correction - To be completed: 08/21/2024
The ratios cannot be corrected as this is an event in the past.
The LPN ratios will be completed and reviewed daily for accuracy by the scheduler.
The facility continues to develop a recruitment plan to attract LPN staff. The facility scheduler, DON, HR and NHA will meet daily to review compliance with ratios. In the event of call offs, every effort to contact regular full-time and part-time staff as well a PRN and agency staff will be made by facility personnel.
Ratios will be monitored daily by the scheduler and DON/designee. Facility compliance with LPN staff ratios will be monitored through the monthly QAPI process. Ratios will be monitored daily by the scheduler and/or DON/designee. Audits of LPN ratios will be completed by the DON/designee daily X 4 weeks then 3 times per week X two months or until substantial compliance is achieved. The results of the audits will be reviewed at the monthly QA meeting.
Date of compliance 8/21/2024
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