Deficiency in Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficiency was identified through a review of the New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Report. The report highlighted multiple instances where the facility did not meet the staffing requirements for certified nurse aides (CNAs) and total staff across various shifts. Specifically, the facility was found to be deficient in CNA staffing for residents on several day shifts, as well as in total staff for residents on some evening and overnight shifts. The deficiency was observed over multiple weeks, with specific dates and staffing numbers provided. For example, on certain days, the facility had significantly fewer CNAs than required for the number of residents present. This pattern of insufficient staffing was consistent across different weeks, indicating a systemic issue rather than isolated incidents. The report detailed specific instances where the number of CNAs and total staff fell short of the mandated ratios, such as having only 2.1 CNAs for 57 residents on a day shift when at least 7 CNAs were required. The Director of Nursing was aware of the staffing ratio criteria, as discussed with the surveyor. However, the facility continued to operate below the required staffing levels, leading to the noted deficiencies. The report does not mention any corrective actions or plans to address these staffing issues, focusing solely on the observed deficiencies and the facility's failure to comply with state staffing mandates.
Plan Of Correction
1. Corrective Action of Areas Affected: The facility cannot retroactively correct the identified concerns related to not meeting the minimum CNA staffing requirements. 2. Other Areas Affected: All residents have the potential to be affected by this deficient practice. On a daily basis, the Staffing Coordinator, Administrator and Director of Nursing review staffing patterns for the current and upcoming days and strategize accordingly in order to start each shift at or above the minimum CNA requirements to the fullest extent possible. 3. Systemic Changes to Prevent Future Occurrences: The facility has implemented a weekly Staffing Committee including the Staffing Coordinator, Director of Nursing, Administrator and Corporate Recruiters and have initiated recruitment/retention strategies for all staff with special focus on nurses and CNAs. Strategies include establishing relationships with local CNA schools, competitors salary analysis, addressing absenteeism, employee recognition/retention, and agency utilization. 4. Monitoring of Corrective Action: The Administrator will submit a report weekly x4 weeks, then monthly x2 months. Results of the audits will be reported at the monthly Quality Assurance Improvement Meetings for review and recommendations.