Failure to Meet CNA Staffing Ratios
Penalty
Summary
The facility failed to meet the mandatory staffing ratios as required by New Jersey law, specifically N.J.S.A. 30:13-18, which mandates minimum staffing levels for nursing homes. During a review of staffing records from December 1, 2024, to December 14, 2024, it was found that the facility did not have the required number of Certified Nurse Aides (CNAs) on four separate day shifts. On December 2 and 3, 2024, the facility had 17 CNAs for 143 residents, falling short of the required 18 CNAs. On December 5, 2024, there were 17 CNAs for 141 residents, again requiring at least 18 CNAs. Finally, on December 13, 2024, the facility had 16 CNAs for 138 residents, when at least 17 CNAs were needed. This deficiency had the potential to affect all residents in the facility.
Plan Of Correction
1) Efforts to hire more facility staff to allow us to have adequate or more than adequate staff to serve our residents have been ramped up. In the meantime, the facility will utilize agencies to fill open slots in the schedule. 2) All residents in the Facility have the potential to be affected by the deficient practice. 3) The Administrator and Director of Nursing shall continue to review the daily Certified Nursing Assistant (CNA) staffing schedules to ensure compliance with the state's minimum CNA staffing requirement. Furthermore, the facility will review its recruitment program and hiring efforts to attract and hire CNAs, as evidenced by placing advertisements on Indeed, contacting recruitment agencies, and offering referral bonuses to current staff for securing additional staff. The center shall offer overtime, incentive pay, and bonuses to current staff when a staffing shortage is identified or occurs throughout the day and/or week. The facility staffing coordinator will work with sister facilities staffing coordinator for CNAs/License Nurses for daily backup when call outs occur. CNAs will receive free meals and incentives on top of their regular pay. The facility will offer overtime, bonuses, or incentives to Licensed Nurses to work as Nursing Assistants when warranted. The facility also maintains an agreement with nursing staffing agencies in the event of any staffing shortage. A meeting was conducted on Tuesday with Staffing Company, HR, and DON to discuss current needs. 4) The Administrator and Director of Nursing or designee shall review/audit the Certified Nursing Assistant (CNA) staffing schedule daily for 4 weeks, then monthly x 2 months, and then quarterly for 3 quarters to determine compliance with the state's minimum CNA staffing requirement. The Administrator shall continue to monitor the facility's recruitment and retention practices to identify potential areas of improvement. The results of these audits will be submitted monthly to the Quality Assurance and Performance Improvement (QAPI) committee for the next 6 months. This will be a part of the Quarterly Quality Assurance Program ongoing. Staffing Coordinator and DON will check staffing sheets the next day and initiate progressive discipline for those who are calling out. Weekend call outs will mandatorily be made up the following weekend. This will be ongoing.