(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 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 overnights shifts for ten of 21 overnight shifts reviewed (December 31, 2023; January 1, 5, and 6, 2024; February 1, 6, 9, 10, 11, and 12, 2024).
Findings include:
Review of facility provided staffing ratio information for December 31, 2023; January 1, 5, and 6, 2024; February 1, 6, 9, 10, 11, and 12, 2024, on the overnight shift, revealed a resident census of 42-55 residents. The information also revealed an LPN ratio of one; therefore, the facility did not meet the minimum LPN ratio required for the facility census of residents on those shifts.
During an interview with the Nursing Home Administrator (NHA) on February 14, 2024, at approximately 2:00 PM, the NHA said they are making an effort to recruit an LPN for the overnight shift, but have been unsuccessful with filling the vacancy or finding an agency person.
| | Plan of Correction - To be completed: 03/26/2024
1. Facility identified no adverse outcome from days identified. 2. Education will be provided by the Administrator to the Nursing Administration, scheduler, and charge nurses on calculation of the ratios and replacement of staff if indicated. 3. A staffing ratio document will be completed daily by the scheduler and reviewed at morning meetings. The ratio document will be updated with any changes in the schedule and reviewed with the DON/Admin Nurse to ensure proper coverage. If a shortage is discovered, will call Part Time and PRN staff, and contract agency staffing to meet staffing ratios. 4. An audit of the ratio document against the deployment sheet will be completed daily for 1 week, weekly for 2 weeks and then biweekly X 2 weeks. Results of the audit will be taken to QAPI for review of findings and further interventions if warranted.
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