(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 nursing time schedules and staff interview it was determined that the facility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per forty residents during the night shift for 2 of 21 days (1/30/24 and 2/3/24).
Findings include:
Review of the facility census data, nursing time schedules, and deployment sheets from 1/30/24 through 2/19/24, revealed the following nurse LPN staffing shortages:
On 1/30/24 the census was 95, which required 2.52 LPN's during the night shift. Review of the nursing time schedules revealed 2.19 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.
On 2/3/24, the census was 100, which required 2.66 LPN's during the night shift. Review of the nursing time schedules revealed 2.42 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.
During an interview on 2/21/24, at 2:30 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a minimum of one LPN per forty residents during the night shift on 2 of 21 days.
| | Plan of Correction - To be completed: 03/11/2024
- The facility is unable to retroactively correct the staffing ratio for days: 2/1/24, 2/2/24, 2/3/24, 2/4/24, 2/5/24, 2/6/24, 2/13/24, 2/15/24, 2/16/24, 2/18/24. - The facility will schedule CNA's, LPN's and RNs to State Ratio. Call outs will be monitored by NHA/DON and/or designee. Facility staff as well as staffing agencies will be utilized to facilitate replacement/procurement of staff. - The staffing ratio will be monitored daily for 5 days, weekly for 2 weeks, and monthly for 2 months. - Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring or changes needed.
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