Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the mandatory staffing ratios as required by New Jersey law, specifically on one of the 14-day shifts reviewed. According to the New Jersey Department of Health memo, effective from February 1, 2021, the law mandates a minimum staffing ratio of one Certified Nurse Aide (CNA) to every eight residents during the day shift. However, on December 1, 2024, the facility had only 10 CNAs for 113 residents, whereas at least 14 CNAs were required to meet the legal staffing ratio. This deficiency was identified during a review of staffing records for the period from November 24, 2024, to December 7, 2024, and had the potential to affect all residents in the facility.
Plan Of Correction
Completion Date: 1/9/2025 CORRECTIVE ACTION: Efforts to hire facility staff will continue until there is adequate staff to serve all residents. Until that time, the facility will utilize staffing agencies to fill any open spots in the schedule. IDENTIFICATION OF THE RESIDENTS AT RISK: All residents have the potential to be at risk for deficient practice. SYSTEMIC CHANGE: The facility Administrator has put in place a bonus structure as to help increase the levels of staffing according to census. Hiring and recruitment efforts including wage analysis and adjustments, pay for experience, online job listings, job fairs, shift differentials, and referral bonuses are being utilized to become more competitive in the marketplace. In addition, the director of nursing or designee will meet daily with the staffing coordinator to ensure appropriate staffing. QUALITY ASSURANCE: The Director of Nursing or designee will review staffing schedules daily to ensure adequate staffing for all shifts. Findings from the review will be reported to the Administrator. Any issue from the findings will be addressed immediately. The results of the staffing review will be submitted to the QA/QAPI Committee quarterly until compliance is met.