(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 a review of nurse staffing schedules it was determined that the facility failed to ensure the minimum licensed practical nurse staff to resident ratio was provided on each shift for 20 shifts out of the 63 shifts reviewed.
Findings include:
A review of the facility's daily employee staffing sheets from December 7, 2023, to December 27, 2023, revealed that the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:30 during the evening shift and 1:40 during the night shift, as per the facility's census.
December 7, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 30 residents. December 8, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 31 residents. December 9, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 33 residents. December 10, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 33 residents. December 11, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 33 residents. December 12, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 33 residents. December 13, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 33 residents. December 14, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 32 residents. December 15, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 32 residents. December 18, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 32 residents. December 19, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 32 residents. December 20, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 32 residents. December 21, 2023 - 1 LPNs during the evening shift, versus the required 2 for a census of 33 residents. December 21, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 33 residents. December 22, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 33 residents. December 23, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 33 residents. December 24, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 32 residents. December 25, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 32 residents. December 26, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 32 residents. December 27, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 32 residents.
During an interview on December 28, 2023, at approximately 10:30 AM, the Director of Nursing confirmed that the facility failed to ensure the minimum licensed practical nurse staff to resident ratio was provided on the above shifts.
| | Plan of Correction - To be completed: 01/31/2024
1. The facility is unable to retroactively provide a minimum LPN ratio for cited dates . 2.A facility wide audit was completed to ensure ratios were met. Recruitment increased LPN sign on bonuses, and wages are competitive with surrounding areas. 3.The DON and Recruitment were re-educated on ensuring that the nursing care ratios are provided, and that the facility is actively recruiting LPNs. 4.The DON or designee will conduct an audit of the nursing care ratios to ensure it is provided weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.
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