Observations:
Based on document review 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 night shifts for 4 of 5 nights reviewed (March 1, 2, 3, and 5, 2024).
Findings Include:
Review of the facility provided staffing ratio information for March 1-5, 2024, on night shift, revealed a resident census of 65-67 residents; thus, requiring a LPN staffing ratio of 1.63-1.68 on those shifts. The information also revealed an LPN ratio of 1.00 on the night shifts of March 1, 2, 3, and 5, 2024, therefore, the facility did not meet the minimum LPN ratio required for the facility census of residents on those shifts.
An interview with the Nursing Home Administrator on March 7, 2024, at 10:15 AM, revealed that they will need to hire another nurse to cover the need.
| | Plan of Correction - To be completed: 04/01/2024
Upon discovery of the shortfall, the administrator reviewed the weekly LPN staffing schedule. The remaining shifts were identified, and it was determined that qualified agency staff LPNs would be utilized to meet the minimum overnight LPN ratio until such time as the remaining fulltime LPN staff member is hired.
The administrator verified that during each of the overnights when the minimum LPN ratio was not met, an additional CNA was scheduled and present to provide residents with extra support and attention, in addition to the attention of the existing overnight LPN and RN Supervisor.
Additionally, the administrator reviewed the overnight LPN staffing pattern and educated the clinical scheduler regarding the needs and nighttime LPN ratio. The clinical scheduler reached out to three (3) agency staff LPNs who are already familiar with the facility and residents. The agency staff are retained under two (2) existing contracts which the home has maintained for several years; Milestone and Pacific.
The administrator and clinical scheduler will audit the schedule daily for 4 weeks, weekly for 2 weeks, and monthly for 3 months to ensure the facility is meeting the overnight LPN staffing ratio for each nightshift ongoing, either via its own employees or through the services of qualified agency LPNs. The staffing calculator provided by the Department, including daily census and actual staffing hours and personnel, will be utilized as a tool to track compliance in addition to timeclock documentation.
The administrator and DON will hold staffing meetings with the recruiter weekly x 6 to ensure the advertisement and recruiting effort for the fulltime overnight LPN position remains in place and is the highest priority. Upon identification of a suitable LPN candidate by the recruiter, DON, and administrator, the fulltime overnight LPN will follow established procedures for hiring and onboarding, and when fully trained will take the place of agency staff.
These steps to fulfill the overnight LPN ratio requirement, audits, education, and all evidence of compliance will be included as a standing agenda item at each of the facility's monthly Quality Assurance and Performance Improvement (QAPI) meetings for review and approval.
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