(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 and staff interview, it was determined that the facility failed to ensure the minimum licensed practical nurse staff to resident ratio was provided on each shift for 23 shifts out of 63 reviewed.
Findings include:
A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:25 on the day shift, 1:30 on the evening shift, and 1:40 on the night shift based on the facility's census.
January 4, 2024 - 3 LPNs on the day shift, versus the required 3.04 for a census of 76. January 4, 2024 - 2.38 LPNs on the evening shift, versus the required 2.53 for a census of 76. January 5, 2024 - 3 LPNs on the day shift, versus the required 3.04 for a census of 76. January 5, 2024 - 2.25 LPNs on the evening shift, versus the required 2.53 for a census of 76. January 5, 2024 - 1.75 LPNs on the night shift, versus the required 1.90 for a census of 76. January 6, 2024 - 3 LPNs on the day shift, versus the required 3.04 for a census of 76. January 6, 2024 - 2.25 LPNs on the evening shift, versus the required 2.53 for a census of 76. January 6, 2024 - 1.63 LPNs on the night shift, versus the required 1.90 for a census of 76. January 7, 2024 - 3 LPNs on the day shift, versus the required 3.04 for a census of 76. January 8, 2024 - 3 LPNs on the day shift, versus the required 3.04 for a census of 76. January 9, 2024 - 3 LPNs on the day shift, versus the required 3.04 for a census of 76. January 10, 2024 - 3 LPNs on the day shift, versus the required 3.04 for a census of 76. January 11, 2024 - 1.75 LPNs on the night shift, versus the required 1.83 for a census of 73. January 12, 2024 - 1.75 LPNs on the night shift, versus the required 1.83 for a census of 73. January 14, 2024 - 2.25 LPNs on the evening shift, versus the required 2.40 for a census of 72. January 15, 2024 - 2 LPNs on the evening shift, versus the required 2.43 for a census of 73. January 15, 2024 - 1.38 LPNs on the night shift, versus the required 1.83 for a census of 73. January 17, 2024 - 3 LPNs on the day shift, versus the required 3.04 for a census of 76. January 18, 2024 - 3 LPNs on the day shift, versus the required 3.16 for a census of 79. January 19, 2024 - 3 LPNs on the day shift, versus the required 3.04 for a census of 76. January 19, 2024 - 1.5 LPNs on the night shift, versus the required 1.90 for a census of 76. January 21, 2024 - 3 LPNs on the day shift, versus the required 3.08 for a census of 77. January 21, 2024 - 1.63 LPNs on the night shift, versus the required 1.93 for a census of 77.
An interview with the Nursing Home Administrator on January 24, 2024, approximately 2:15 PM, confirmed the facility had not met the required LPN to resident ratios on the above dates.
| | Plan of Correction - To be completed: 02/12/2024
1. Facility is unable to correct past deficiency.
2. The facility has an active recruitment/retention plan to fill open positions which includes supplemental staffing bonuses to cover vacancies. The facility will ensure that general nursing hours are being met for each shift.
3. Staff Scheduler, DON, HR will be educated on the importance of meeting LPN ratios, and that the facility is actively recruiting LPNs.
Agency will be utilized for open shifts as needed and available.
Calculation of daily shift ratios will be completed and reviewed daily for accuracy by the scheduler and DON. All efforts will be made to meet the staffing ratio.
If call offs occur, all efforts will be made to attempt to fill that position with LPN's that are working in ancillary departments.
4.The DON or designee will conduct an audit of the LPN ratios to ensure ratios are being met weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and re-evaluation.
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