(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.
|
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 25 residents on day shift for two of seven days reviewed (February 10 and 13, 2024); a minimum of one LPN per 30 residents on evening shift for one of seven days reviewed (February 13, 2024); and a minimum of one LPN per 40 residents on night shift for five of seven days reviewed (February 7, 9, 10, 12, and 13, 2024).
Findings include:
Review of the facility provided staffing ratio information for the day shift on February 10 and 13, 2024, revealed a census ranging from 161-162. The information also revealed the facility was not meeting the required LPN ratio of 6.44 to 6.48 required for the facility census of residents on those shifts.
Review of the facility provided staffing ratio information for the evening shift February 13, 2024, revealed a census of 161. The information also revealed the facility was not meeting the required LPN ratio of 5.37 required for the facility census of residents on this shift.
Review of the facility provided staffing ratio information for the night shift on February 7, 9, 10, 12, and 13, 2024, revealed a census ranging from 160-162. The information also revealed the facility was not meeting the required LPN ratio of 4.00 to 4.05 required for the facility census of residents on those shifts.
In an email received from the Director of Nursing on February 15, 2024, at 11:43 AM, she indicated that she had no additional information to offer.
| | Plan of Correction - To be completed: 04/19/2024
1. The ratios noted in the survey findings cannot be corrected as this is a past event. 2. Calculation of shift ratios by discipline (CNA and LPN) will be completed and reviewed daily for accuracy the scheduler. 3. The facility has developed recruitment plan to attract staff and meet shift ratio requirements. Facility scheduler, DON, HR, and NHA have daily staffing meetings to review schedules including compliance with ratios. For staff call offs, every effort will be made to replace the call off using resources available including communicating with staff to replace the vacancy. Staffing patterns are projected at least one week in advance to enable ongoing efforts to fill any vacant shifts. 4. Ratios will be monitored daily by Scheduler and DON/designee. Facilities ability to accept admissions will be reviewed daily during daily staffing meeting. Facility compliance with ratios will be reviewed during monthly QAPI meeting with IDT.
|
|