Staffing and Mask-Wearing Deficiencies
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey. This deficiency was observed over multiple periods, including specific weeks in October 2023, June to July 2024, and December 2024. During these times, the facility consistently had fewer Certified Nurse Aides (CNAs) than required for the day shifts, and there were also deficiencies in total staff numbers for evening and overnight shifts. Interviews with the Human Resources director and the Director of Nursing revealed attempts to meet staffing ratios through bonuses and agency staff, but these efforts were not always successful. Additionally, the facility did not ensure that employees with medical exemptions from the influenza vaccine wore surgical or procedural masks when in direct contact with patients and in common areas, as required by New Jersey law. The surveyor observed that two employees, a dietary employee and an activity employee, were not wearing masks despite having medical exemptions from the influenza vaccine. Interviews with these employees indicated a lack of awareness or enforcement of the mask-wearing requirement. The facility's policy on influenza vaccination did not address the use of masks for employees with medical exemptions. The Director of Nursing was unaware of the requirement for these employees to wear masks, which contributed to the deficiency. The facility's failure to comply with staffing ratios and mask-wearing requirements for exempt employees highlights significant lapses in adhering to state regulations designed to ensure resident safety and care quality.
Plan Of Correction
Element 1 It is the practice of the facility to ensure that the minimum direct care staff-to-shift ratios are in compliance with the mandate from the State of New Jersey. The deficiency is being corrected by offering bonuses and overtime to staff to cover openings/callouts in the schedule, offering openings/callouts to staffing agencies, utilizing job search engines (Apploi) to expand the view of job postings, and meeting with Certified Nursing Assistant schools to speak with newly graduating individuals. Additionally, all staff members who are Medically Exempt from receiving the Flu Vaccine were immediately informed they must wear a surgical mask while within the facility, and given masks to wear. Element 2 All residents are affected by this deficiency. Element 3 The deficiency is being corrected by offering bonuses and overtime, utilizing staffing agencies, utilizing job search engines (Apploi), and meeting with Certified Nursing Assistant schools to speak with newly graduating individuals. Additionally, a Staffing Audit is being conducted by the Staffing Coordinator to ensure the facility remains in compliance with S560. Staff were also educated that they must wear a mask while in the facility if they are Medically Exempt from receiving the Flu Vaccine; a Mask Audit is being conducted by the Infection Preventionist to ensure the facility remains in compliance. Element 4 To maintain and monitor ongoing compliance, the Staffing Audit is being monitored by the Administrator or designee once a week for two months, then once every other week for two months, and then once a month for two months. Additionally, the Mask Audit is being monitored by the Director of Nursing or designee once a week for two months, then once every other week for two months, and then once a month for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.