(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 nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one licensed practical nurse per 25 residents during the day on six of 14 day shifts reviewed and failed to ensure a minimum of one licensed practical nurse per 40 residents on 10 of 14 days reviewed.
Findings include:
Review of nursing staff care hours provided by the facility revealed the following licensed practical nurse (LPN)scheduled for the following resident census:
Day shift:
February 27, 2024, 4.69 LPNs for a census of 118 requires 4.72 LPNs.
March 2, 2024, 4.38 LPNs for a census of 113, requires 4.52 LPNs.
March 3, 2024, 3.88 LPNs for a census of 113, requires 4.52 LPNs.
March 6, 2024, 4.31 LPNs for a census of 112, requires 4.48 LPNs.
March 7, 2024, 3.94 LPNs for a census of 113, requires 4.52 LPNs.
March 8, 2024, 4.03 LPNs for a census of 114, requires 4.56 LPNs.
Overnight shift:
February 26, 2024, 2.72 LPN for a census of 118, requires 2.95 LPNs.
February 28, 2024, 2.31 LPNs for a census of 115 requires 2.88 LPNs.
February 29, 2024, 2.31 LPNs for a census of 115, requires 2.31 LPNs.
March 1, 2024, 2.41 LPNs for a census of 114, requires 2.85 LPNs.
March 2, 2024, 2.09 LPNs for a census of 111, requires 2.78 LPNs.
March 3, 2024, 2.13 LPNs for a census of 113, requires 2.83 LPNs.
March 4, 2024, 2.31 LPNs for a census of 111, requires 2.83 LPNs.
March 5, 2024, 2.16 LPNs for a census of 112, requires 2.80 LPNs.
March 7, 2024, 2.34 LPNs for a census of 114, requires 2.85 LPNs.
March 8, 2024, 2.06 LPNs for a census of 113, requires 2.83 LPNs.
Email communication with the Nursing Home Administrator on March 11, 2024, at 2:16 PM acknowledged the above findings.
| | Plan of Correction - To be completed: 03/20/2024
1. Facility will continue to take measures to adequately provide staff to ensure the needs of residents are met.
2. The Director of Nursing or designee will provide re-education on minimum staffing ratios to RN Supervisors, Human Resources and Scheduling Coordinator who are responsible to maintain adequate staffing and staffing ratios.
3. The Director of Nursing or designee will audit the daily schedules to ensure the minimum number of staff to resident ratios have been scheduled and will audit that protocols were followed if a call off occurred.
4. Audits will be completed weekly and results of these audits will be reviewed at Quality Assurance and Process Improvement Meetings until substantial compliance is achieved.
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