(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 staffing documents and staff interview, it was determined that the facility failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift for two of 21 days reviewed (4/28/24, and 5/4/24), failed to provide a minimum of one LPN per 30 residents during the evening shift for two of 21 days reviewed (4/26/24, and 5/2/24), and failed to provide a minimum of one LPN per 40 residents during the overnight shift for six of 21 days reviewed (4/29/24, 4/30/24, 5/1/24, 5/2/24, 5/3/24, and 5/4/24).
Findings include:
Review of facility staffing ratio information for the time period from 4/26/24, through 5/16/24, revealed the following LPN staffing shortages for the day shift where the NA ratios were not met:
4/28/24 census of 92 residents 3.03 LPNs worked and 3.68 were required
5/04/24 census of 87 residents 3.33 LPNs worked and 3.48 were required
Review of facility staffing ratio information for the time period from 4/26/24, through 5/16/24, revealed the following LPN staffing shortages for the evening shift where the NA ratios were not met:
4/26/24 census of 93 residents 2.70 LPNs worked and 3.10 were required
5/02/24 census of 92 residents 3.02 LPNs worked and 3.07 were required
Review of facility staffing ratio information for the time period from 4/26/24, through 5/16/24, revealed the following LPN staffing shortages for the overnight shift where the NA ratios were not met:
4/29/24 census of 94 residents 1.72 LPNs worked and 2.35 were required
4/30/24 census of 93 residents 1.96 LPNs worked and 2.33 were required
5/01/24 census of 92 residents 2.29 LPNs worked and 2.30 were required
5/02/24 census of 92 residents 1.99 LPNs worked and 2.30 were required
5/03/24 census of 87 residents 1.73 LPNs worked and 2.18 were required
5/04/24 census of 88 residents 1.16 LPNs worked and 2.20 were required
During a telephone interview on 6/07/24, at 3:56 p.m. the Nursing Home Administrator confirmed that the facility did not meet the minimum LPN ratios for the above days and shifts.
| | Plan of Correction - To be completed: 07/15/2024
1. The facility must maintain the minimum of one Licensed Practical Nurse (LPN) per 25 residents on the day shift, and 1 LPN per 30 residents on the evening shift and one LPN for every 40 residents on the overnight shift.
2. To ensure that this regulatory requirement is met the following action plan will be implemented:
Education will be provided to the scheduler and the Director of Nursing to ensure that they understand the regulatory staffing requirements for Licensed Practical Nurses.
The LPN schedule will be reviewed by the scheduler and Director of Nursing or designee to ensure that LPN ratios are met prior to posting of the schedule.
In the event of call-offs by staff, all other staff/agency will be contacted to cover any open shifts to ensure ratios are met. The Director of Nursing or designee and or the Scheduler are responsible for handling call-offs on the off shifts and weekends.
The Administrator and Director of Nursing will monitor staff ratios in relation to current census and place a hold on new admissions if staffing ratios would not be met.
The Administrator, Director of Nursing, scheduler and human resource director will continue to report staffing vacancies on the weekly staffing call with the firm that manages recruitment and retention and discuss strategies to increase recruitment of nursing personnel.
3. An audit will be developed and completed by the Director of Nursing or Designee daily for 4 weeks, then 3 times a week for 3 weeks, then 2 times a week for 2 weeks then weekly ongoing, to ensure that LPN ratios are met for the day, evening and overnight shifts. The audit will be monitored by the Administrator or Designee.
Results of the audit will be presented at the next three QAPI meetings and recommendations will be implemented.
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