(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 the facility staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one Licensed Practical Nurse (LPN) per 25 residents for the day shift for one of 14 days reviewed (5/31/24 ), failed to ensure one LPN per 30 residents for evening shift for seven of 14 days reviewed (5/20/24, 5/21/24, 5/22/24, 5/23/24, 5/24/24, 5//27/24,and 5/29/24), and failed to ensure one LPN per 40 residents for the overnight shift for six of 14 days reviewed (5/19/24, 5/20/24, 5/21/24, 5/22/24, 5/23/24 and 5/24/24).
Findings include:
Review of facility staffing ratio information for the time period from 5/19/24 through 6/01/24, revealed the following LPN staffing shortages for the day shift where the LPN ratios were not met:
5/31/24 census of 57 residents 2.24 LPNs worked and 2.28 were required
Review of facility staffing ratio information for the time period from 5/19/24 through 6/01/24, revealed the following LPN staffing shortages for the day shift where the LPN ratios were not met:
5/20/24 census of 57 residents 1.43 LPNs worked and 1.90 were required
5/21/24 census of 57 residents1.82 LPNs worked and 1.90 were required
5/22/24 census of 57 residents 1.70 LPNs worked and 1.90 were required
5/23/24 census of 56 residents1.43 LPNs worked and 1.87 were required
5/24/24 census of 56 residents1.12 LPNs worked and 1.87 were required
5/27/24 census of 55 residents 1.00 LPNs worked and 1.83 were required
5/29/24 census of 56 residents1.82 LPNs worked and 1.87 were required
Review of facility staffing ratio information for the time period from 5/19/24 through 6/01/24, revealed the following LPN staffing shortages for the overnight shift where the LPN ratios were not met:
5/19/24 census of 55 residents 1.18 LPNs worked and 1.38 were required
5/20/24 census of 55 residents1.04 LPNs worked and 1.38 were required
5/22/24 census of 57 residents 1.17 LPNs worked and 1.43 were required
5/22/24 census of 57 residents1.17 LPNs worked and 1.43 were required
5/23/24 census of 56 residents1.18 LPNs worked and 1.40 were required
5/24/24 census of 56 residents 1.19 LPNs worked and 1.40 were required
During a telephone interview on 6/05/24, at 1:42 p.m. the Nursing Home Administrator confirmed the LPN ratios were not met for the above dates and shift.
| | Plan of Correction - To be completed: 07/18/2024
The facility will continue to attempt to attain the minimum nurse LPN to resident ratio each day by calculating out projected ratios needed at current census levels. Ongoing educations to the DON and the schedular and the unit manager to review on ensuring that the facility meets the required minimum LPN to resident ratio. We have instituted the following system changes to ensure we meet the staffing ratios: We have a Staffing Schedular Computer Program that will predict our staffing needs. This program will alert staff of openings to meet staffing needs. Management staff designee will review potential admission numbers to ensure appropriate census levels are maintained. We will continue offer additional time to our staff members which may include agency and continue to offer extra shift bonuses for current employees, ensure all our vacant positions are currently in recruitment and advertised appropriately. The Director of Nursing or designee will audit to ensure that facility meets the required minimum number of LPN to resident staffing ratio by reviewing the current working schedule and assignment sheets prior to the day and after the day is complete to ensure compliance. Monitoring will be conducted three times a week for one month, then two times a week for 4weeks. Monitoring will be reviewed at the quarterly QAPI Meeting and additional recommendations will be followed as deemed appropriate.
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