Deficiency in CNA Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff to resident ratios for 12 out of 14 day shifts, as mandated by the State of New Jersey. According to the New Jersey Department of Health memo dated 01/28/2021, the law requires one Certified Nurse Aide (CNA) for every eight residents during the day shift. However, the facility's 'Nurse Staffing Report' for the period from 12/01/2024 to 12/14/2024 showed that the facility was consistently understaffed. For instance, on 12/01/24, there were only 13 CNAs for 178 residents, whereas at least 22 CNAs were required. Similar deficiencies were noted on other days, with the number of CNAs consistently falling short of the required number. Interviews conducted on 12/20/24 with the Staffing Coordinator and the Director of Nursing revealed that both were aware of the minimum staffing ratio requirements. Despite this awareness, they stated that the facility was meeting the requirements, which contradicts the documented staffing levels. The facility's policy titled 'Staffing', revised in 4/2024, claims that adequate staffing is provided to meet the care and service needs of the residents, yet the documented staffing levels indicate otherwise.
Plan Of Correction
S560 Staffing Levels What corrective action will be accomplished for those residents affected by the deficient practice? No residents were identified. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by the deficient practice. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? On January 6, 2025, the Administrator provided re-education to the Director of Nursing, Assistant Director of Nursing, and the Human Resources Director on the minimum staffing requirements by shift for certified nurse aides (direct care staff) by the Department of Health. The Administrator, Director of Nursing, Human Resources Director, and/or Staffing Coordinator will meet weekly to review staffing levels for the week, open positions, and recruitment efforts. The facility will focus on recruitment and retention including but not limited to, use of web-based recruitment advertising, contract utilization, sign-on bonuses and referral bonuses, job fairs, shift differentials, and employee moral incentives. The Human Resources Director will utilize the Recruitment Report to track and trend recruitment efforts weekly x4 weeks, then 2x a month for 2 months. How will the corrective action be monitored to ensure the deficient practice will not recur? The Human Resources Director and/or Designee will review and report the audit results during the Quality Assurance Performance Improvement (QAPI) meeting monthly x3 months. The QAPI meeting is attended by the Administrator, Director of Nursing, Medical Director, and Department Heads.