(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 facility-provided staffing data 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 the overnight shift for one of eight days reviewed (February 2, 2024).
Findings include:
Review of facility provided staffing ratio/resident census information for January 30, 2024, and February 2-8, 2024, revealed the following LPN ratio, which did not meet the minimum LPN ratio required for the facility census of residents on those shifts: February 2nd night shift - 136 residents and 3.19 LPNs.
In email correspondence received from the Director of Nursing on February 9, 2024, at 10:13 AM, she confirmed that the facility was unable to meet the LPN staffing ratio as noted above despite efforts to cover the shift.
| | Plan of Correction - To be completed: 04/02/2024
1. Nursing ratios were adjusted to ensure a 1:25/30/40 ratio on days, evenings and nights. 2. Nursing ratios will be scheduled at a 1: 25/30/40 ratio for day, evening and night shifts. Weekly labor management calls with HRD, NHA, DON and scheduler to review current and expected staffing needs are ongoing. Three RNs participate in an on-call rotation to be notified of any call outs that fall below the state minimum ppd and nurse and CNA ratios. 3. Education has been provided to the scheduler and HRD to ensure appropriate LPN ratios are met daily per regulations. Education has been provided to clinical staff about the attendance policy and the consequences of the attendance infractions. Education on the ratios will be provided to department heads and nursing supervisor staff that report to nursing administration on call. 4. DON/designee will do random audits of 5 shifts per week for 4 weeks to ensure compliance. Results will be submitted to QAPI to determine if audits will continue beyond 4 weeks.
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