Observations:
Based on review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift, per 30 residents during the evening shift, and per 40 residents during the night shift on one of 21 days (12/12/23).
Findings include:
Review of the facility census data, nursing time schedules, and deployment sheets revealed the following LPN staffing shortages:
-12/12/23, Census 136. Night shift short two LPN.
During an interview on 1/30/24, at1 1:15 p.m. the Nursing Home Administrator confirmed that the facility failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift, per 30 residents during the evening shift, and per 40 residents during the night shift one of 21 days on 12/12/23.
| | Plan of Correction - To be completed: 03/04/2024
Nursing administration reviewed the date of 12/12/23 that the license practical nurse ratio was below the minimum of 1:40 residents on the night shift. There were no identified adverse effects relating to residents regarding the deficiency in licensed nurse ratio. The hours per patient day on the date identified was 3.30 which is well above the state minimum of 2.87. Nursing administration and the scheduling team meets daily to review staffing, ratios, and census to make every effort to secure the staffing needed to meet the state's regulatory requirement. The team reviews census, patient care needs, and available nursing staff including current staff and agency staff to ensure we are meeting the needs of the residents. The nursing administration team works diligently and creatively to recruit for our open positions and incentivize the appropriate team members to fill our open shifts. The team utilizes staffing incentives for current team members who help to fill open shifts. The team also reaches out to our contracted agencies to find the appropriate agency staff to fill shifts that are remain open. Management nurses are on call to respond to staffing shortages. NHA/DON or designee will complete a weekly audit and do everything possible to meet the licensed nurse requirement that became effective on July 1, 2023. The audit will be completed weekly for four weeks. Results of audits will be presented to the Quality Assurance Performance Improvement Committee for review and recommended follow up action.
|
