(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.
|
Observations:
Based on document review and staff interview, it was determined that the facility failed to ensure a required minimum of Licensed Practical Nurses (LPN) on evening and night shifts for five of seven days reviewed (January 18, 20, 21, 22, and 23, 2024).
Findings Include:
Review of facility provided staffing ratio information for January 18, 22, and 23, 2024, on evening shift, revealed a resident census of 21-23 residents. The information also revealed that the facility did not have a LPN working for the full eight hour shift; therefore, the facility did not meet the minimum nurse aide ratio of one LPN required for the facility census of residents on those shifts.
Review of facility provided staffing ratio information for January 20 and 21, 2024, on night shift, revealed a resident census of 21-23 residents. The information also revealed that the facility did not have a LPN working for the full eight hour shift; therefore, the facility did not meet the minimum nurse aide ratio of one LPN required for the facility census of residents on those shifts.
During an interview with the Nursing Home Administrator on January 25, 2024, at 12:10 PM, he confirmed that they did not meet the LPN ratio on the aformentioned dates.
| | Plan of Correction - To be completed: 03/26/2024
1. The facility cannot retroactively produce overnight/ evening LPN coverage to meet the ratio requirements on January 18, 20, 21, 22, and 23 2024.
2. The facility is currently in the process of interviewing candidates to fill the overnight LPN position. Facility will purchase INDEED services to help bolster recruiting effort. Facility will work with Career Link and establish relationships with local vocational schools in an effort to bolster recruiting for the position. Facility will implement shift differential for both evening and night shift LPN to increase marketability of the LPN evening and night shift position.
3. DON/Designee will re-educate the nursing scheduler on the LPN to resident overnight ratios to ensure understanding that the regulation indicates that the facility must use a charge nurse LPN and floor LPN. HR will be educated on marketing Shift Differential to new candidates. DoN will report LPN need daily at morning meeting and incentives will be offered to currently staffed LPN's to pick up the shift to ensure the regulation is met if applicable to schedule. Contracts will be offered to LPN staff with enhanced wages to incentive pickup of shift.
4. DON/Designee will conduct a random audit of LPN overnight staffing rations 2x per week for 4 weeks then 2x per month for 2 months and report results to the QAPI meeting.
|
|
