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 40 residents on night shift for one of six days reviewed (June 4, 2024).
Findings Include:
Review of facility-provided staffing ratio information for June 4, 2024, on night shift, revealed a census of 183 residents. Further review revealed a LPN ratio of 4; therefore, the facility did not meet the required minimum LPN ratio for the facility census on that shift.
In an email exchange with the DON on June 12, 2024, at 3:00 PM, he stated that someone had called off.
| | Plan of Correction - To be completed: 07/09/2024
P5530
1. An immediate correction cannot be performed.
2. Calculation of shift LPN ratios will be completed and reviewed daily for accuracy and compliance by scheduler and DON/designee.
3. The facility has agency contracts in place in efforts to meet daily LPN ratios. The facility has also incorporated sign-on bonuses in an effort to attract and retain new staff. When applicable, the facility is also offering shift bonuses in an effort to meet daily LPN ratios. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate LPN ratios as needed. The facility will monitor census each shift and make all attempts to adjust LPN staffing to ensure ratio requirements are met.
4. LPN ratios will be audited by DON/designee daily for 4 weeks, then 3 days per week x2 months or until substantial compliance is achieved. Results to QAPI.
5. Date of Compliance 7.9.24
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