(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 schedules and staffing information furnished by the facility, as well as staff interviews, it was determined that the facility failed to ensure a minimum of one Licensed Practical Nurse (LPN) per 25 residents on the day shift for 12 of 14 days, failed to ensure a minimum of one LPN per 30 residents on the evening shift for 13 of 14, and failed to ensure a minimum of one LPN per 40 residents on the night shift for 9 of 14 days (24-hour periods) reviewed.
Findings include:
Review of facility census data indicated that on August 7, 13, 14, 15, 19, 2024, the facility census was 39, which required 1.56 LPNs during the day shift. Review of the nursing time schedules revealed 1.00 LPNs provided care on the day shift on the August 7, 13, and 14, and 0.94 LPNs on August 15 and 19, 2024.
Review of facility census data indicated that on August 8-10, 2024, the facility census was 41, which required 1.64 LPNs during the day shift. Review of the nursing time schedules revealed 1.00 LPNs provided care on the day shift on August 9 and 10, and 0.94 LPNs on August 8, 2024.
Review of facility census data indicated that on August 6, 2024, the facility census was 38, which required 1.52 LPNs during the day shift. Review of the nursing time schedules revealed 1.00 LPNs provided care on the day shift on August 6, 2024.
Review of facility census data indicated that on August 12, 17, and 18, 2024, the facility census was 40, which required 1.60 LPNs during the day shift. Review of the nursing time schedules revealed 0.94 LPNs provided care on the day shift on August 12, 1.06 LPNs on August 17, and 1 LPN on August 18, 2024.
Review of facility census data indicated that on August 7, 13-15, and 19, 2024, the facility census was 39, which required 1.30 LPNs during the evening shift. Review of the nursing time schedules revealed 1.00 LPNs provided care on the evening shift on August 7, 13, 15, and 19, and 1.06 LPNs on August 14, 2024.
Review of facility census data indicated that on August 8-10, and 16, 2024, the facility census was 41, which required 1.37 LPNs during the evening shift. Review of the nursing time schedules revealed 1.00 LPNs provided care on the evening shift on the dates listed above.
Review of facility census data indicated that on August 6, 2024, the facility census was 38, which required 1.27 LPNs during the evening shift. Review of the nursing time schedules revealed 1.00 LPNs provided care on the evening shift on August 6,2024.
Review of facility census data indicated that on August 12, 17, and 18, 2024, the facility census was 40, which required 1.33 LPNs during the evening shift. Review of the nursing time schedules revealed 1.00 LPNs provided care on the evening shift on the dates listed above.
Review of facility census data indicated that on August 8, 10, and 16, 2024, the facility census was 41, which required 1.03 LPNs during the night shift. Review of the nursing time schedules revealed 0.94 LPNs provided care on the night shift on the dates listed above.
Review of facility census data indicated that on August 9, 12, 14, 17-19, 2024, the facility census was 39, which required 1.00 LPNs during the night shift. Review of the nursing time schedules revealed 0.94 LPNs provided care on the night shift on the dates listed above.
Interview with the Nursing Home Administrator on August 26, 2024, at 10:25 a.m. confirmed that the facility did not meet the required LPN-to-resident staffing ratios for the day listed above.
| | Plan of Correction - To be completed: 09/06/2024
The facility will continue to take measures to adequately provide staff to meet the required Licensed Professional Nurse to resident ratios on all shifts including evaluation of new staffing contracts. When total licensed professional nurse to resident ratios is unable to be met, the facility will reevaluate the scheduling of new admissions.
The Director of Nursing or designee will provide education on minimum staffing ratios to the Registered Nurse Supervisor and Scheduler who are responsible to maintain adequate staffing and staffing ratios.
The Director of Nursing or designee will audit daily schedules to ensure minimum number of staff are scheduled to meet the needs of the residents. These audits will be conducted daily for 7 days and weekly for 2 weeks.
The results will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance has been met.
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