Deficiency in CNA Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficiency was identified through a review of the facility's Nurse Staffing Report (AAS-11) and interviews with facility staff. The report highlighted multiple instances where the facility did not meet the staffing requirements for Certified Nurse Aides (CNAs) during the day shift across several weeks in 2023 and 2024. For example, during the week of October 29, 2023, to November 4, 2023, the facility was deficient in CNA staffing on four out of seven day shifts, with the number of CNAs ranging from 13 to 21, while at least 25 were required for the number of residents present. Further deficiencies were noted in subsequent periods, including April 28, 2024, to May 11, 2024, where the facility was deficient on 11 out of 14 day shifts. The number of CNAs ranged from 16 to 21, while at least 25 were required for the resident count. Similar patterns of insufficient staffing were observed in August and November 2024, with the facility consistently failing to meet the mandated staffing ratios. These deficiencies were confirmed through interviews with the Staffing Coordinator and the Director of Nursing, both of whom claimed that the facility met the staffing requirements despite evidence to the contrary. The facility's policy titled "Staffing," revised in March 2020, stated that the facility would provide sufficient numbers of staff with the necessary skills and competency to care for all residents. However, the documented staffing levels did not align with this policy, as the facility repeatedly failed to meet the minimum staffing requirements based on the residents' needs and the state-mandated ratios. This discrepancy between policy and practice contributed to the identified deficiency in staffing levels.
Plan Of Correction
Plan of Correction S560 Completion Date: 1/15/2025 Corrective Action: - No residents were identified - Staffing levels were reviewed for all deficient dates listed - Additional staff were recruited to meet the minimum staffing standards moving forward ID Other Residents: - Potential to affect all residents residing within the facility Systemic Change: - Bonuses are offered for double shifts, extra shifts, and weekends - Perfect attendance bonuses are offered on a weekly basis - In-service Lateness and Attendance Policy - Usage of Staffing Agencies to supplement staffing needs - Offering of Certified Nursing Assistant Courses within the facility - Referral Program promoted for staff - Sign on bonuses to assist with staff recruitment - Employee Appreciation parties - In-service State Mandated Staffing Levels: to the Nursing Department by Nursing Administration by 1/15/2025 - Additional shifts will be made available to meet staffing levels for Certified Nursing Assistants - Licensed staff will supplement Certified Nursing Assistant positions if the need arises that staffing levels go below the state required minimum Monitoring: - Nursing Administration will conduct weekly CNA staffing schedule audits - Nursing Administration will report findings to the Administrator - Results of the audits will be brought to QA/QAPI on a quarter basis for 3 quarters.