(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 (LPN) staff to resident ratio was provided on the day, evening, and night shifts for 4 shifts out of 21 reviewed.
Findings include:
A review of the facility's weekly staffing records from February 14, 2024, through February 20, 2024, revealed that on the following dates the facility failed to provide minimum LPN staff of 1:25 on the day shifts, 1:30 on the evening shifts, and 1:40 on the night shifts based on the facility's census.
Review of facility census data indicated that on February 14, 2024, the facility census was 51, which required 16.32 hours of LPN's during day shift.
Review of the nursing time schedules revealed 2.04 LPNs provided care on the day shift on February 14, 2024, for a total of 16.30 hours. No additional excess higher-level staff were used to compensate this deficiency.
Review of facility census data indicated that on February 14, 2024, the facility census was 50, which required 13.33 hours of LPNs during evening shift.
Review of the nursing time schedules revealed 1.64 LPNs provided care on the evening shift on February 14, 2024, for a total of 13.13 hours. No additional excess higher-level staff were used to compensate this deficiency.
Review of facility census data indicated that on February 17, 2024, the facility census was 49, which required 9.80 hours of LPNs during night shift.
Review of the nursing time schedules revealed 1.13 LPNs provided care on the night shift on February 17, 2024, for a total of 9.00 hours. No additional excess higher-level staff were used to compensate this deficiency.
Review of facility census data indicated that on February 20, 2024, the facility census was 47, which required 12.53 hours of LPNs during evening shift.
Review of the nursing time schedules revealed 1.00 LPNs provided care on the evening shift on February 20, 2024, for a total of 8.00 hours. No additional excess higher-level staff were used to compensate this deficiency.
An interview with the Nursing Home Administrator on February 21, 2024, at approximately 12:35 PM, confirmed the facility had not met the required minimum licensed practical nurse (LPN) to resident ratios on the day, evening, and night shifts on the above dates.
| | Plan of Correction - To be completed: 03/12/2024
1.The facility cannot retroactively correct the past LPN staffing ratio deficiency.
2.Moving forward, the facility will continue to schedule staff in accordance with the mandated LPN ratio requirements. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios.
3.To prevent this from reoccurring, the RDCS reeducated the NHA; DON and Scheduler on the updated staffing regulations in relation specifically to the LPN staff/resident ratios.
4.To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility is staffed in accordance with the LPN mandated requirements. Audits will be completed 5x weekly x4 weeks; 3x weekly x1 month and weekly x1 month. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
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