Failure to Meet Mandatory Nurse Staffing Requirements
Penalty
Summary
The facility failed to meet the mandatory nurse staffing requirements as outlined by New Jersey regulations for one day during the period from December 1, 2024, to December 14, 2024. Specifically, on December 1, 2024, the facility provided 360 actual staffing hours, which was 19.25 hours less than the required 379.25 staffing hours. This deficiency was identified through a review of the Nurse Staffing Reports for the specified weeks. During an interview on December 20, 2024, the Director of Nursing (DON) acknowledged that the facility's staffing was based on New Jersey's minimum requirements and the residents' acuity levels. The DON admitted that there were occasional days with low staffing but was unsure of the reasons behind these occurrences. The facility's staffing policy, revised in June 2024, stated that staffing ratios would be reviewed and adjusted based on resident acuity and care needs, ensuring sufficient personnel to provide high-quality care. However, the facility did not meet these requirements on the specified date.
Plan Of Correction
1. No residents were affected by not meeting the State of NJ minimum staffing requirements as determined by routine monitoring and review on those dates that no significant changes were noted. 2. All residents could be affected by not meeting State of NJ minimum staffing requirements. 3. Recruitment and retention efforts continue to include: a. Job fairs b. Daily staffing meetings and weekly Regional Labor Management reviews c. Training mentor program to support retention d. Culture committee to improve and maintain staff morale 5. Recruitment bonus and sign-on bonuses offered. 6. Competitive wage analysis. 7. Hired Elite Recruiting to support increased recruiting of nurses and aides. 8. Weekend warrior program started. 4. To monitor and maintain ongoing compliance, the Director of Nursing or designee will monitor staffing daily for 1 week, weekly for 3 weeks, and monthly for 3 months. Results will be presented to the Quality Assurance and Performance Improvement team monthly for continued review and recommendations until substantial compliance is maintained.