Failure to Meet Mandatory Nurse Staffing Requirements
Penalty
Summary
The facility failed to meet the mandatory nurse staffing requirements as outlined in N.J.A.C. 8:39-25.2(b)(1)&(2) for two days during the week of December 1, 2024. Specifically, on December 1, 2024, the facility provided 480 actual staffing hours, which was 33 hours short of the required 513 hours. Similarly, on December 2, 2024, the facility provided 504 actual staffing hours, falling short by 9 hours. This deficiency was identified through a review of the Supplementary Nurse Staffing Report for the weeks of December 1, 2024, to December 14, 2024. Interviews conducted on December 20, 2024, with the Staffing Coordinator, Director of Nursing (DON), and the Licensed Nursing Home Administrator revealed differing perspectives on staffing adequacy. The Staffing Coordinator indicated reliance on the facility census for scheduling, while the DON asserted that registered nurses were available 24/7 and that staffing requirements were met. The Licensed Nursing Home Administrator emphasized staffing based on resident acuities, claiming the facility was correctly staffed. Despite these assertions, the facility's policy, revised in April 2024, stated that adequate staffing should be maintained to meet resident care needs, which was not achieved on the specified days.
Plan Of Correction
S1680- Mandatory Nurse Staffing 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 professional nurses and 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 professional nurse and certified nurse aides 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.