Facility Fails to Meet Mandatory Staffing Ratios
Penalty
Summary
The facility failed to meet the mandatory staffing ratios as required by New Jersey law, specifically N.J.S.A. 30:13-18, which mandates minimum staffing levels in nursing homes. The deficiency was identified during a review of staffing records over several weeks, revealing that the facility did not have the required number of Certified Nurse Aides (CNAs) on multiple day shifts. This failure to comply with staffing requirements had the potential to affect all residents in the facility. The report details specific instances where the facility was understaffed. For example, during the week of May 21, 2023, to May 27, 2023, the facility was short of CNAs on two day shifts. Similar deficiencies were noted in subsequent weeks, including significant shortfalls in CNA staffing during the weeks of July 23, 2023, to August 5, 2023, and October 22, 2023, to October 28, 2023. These staffing shortages were consistent across various weeks, indicating a pattern of non-compliance with the mandated staffing ratios. The report highlights that the facility's staffing deficiencies were not limited to day shifts but also included evening and overnight shifts. For instance, during the week of November 3, 2024, to November 9, 2024, the facility was deficient in both CNA staffing and total staff on several shifts. The consistent failure to meet staffing requirements across multiple weeks and shifts underscores a systemic issue within the facility's staffing practices.
Plan Of Correction
I. Corrective Action accomplished for Resident(s) affected: Director of Nursing/Designee meets daily and before weekends with staffing coordinator to review staff sufficiency. Staffing coordinators will send daily emails with the staffing number to the Administrator and Director of Nursing and ADON's and Nursing Supervisor. II. Residents identified having the Potential to be affected and corrective action taken: All residents residing in the facility had the potential to be affected. A random sample of Twenty alert and oriented residents were interviewed regarding staff response times to requests for assistance with concerns reported to the Director of Nursing for rectification. III. Measures to be put in place to ensure the deficient practice will not recur: The Call Out Policy was reviewed by the facility administration and staff have been reeducated by the Facility Educator on the policy. Referral and Sign-on Bonuses are offered for both Licensed and Certified Nursing Staff. The Retention and Recruitment Coordinator and Nurse Educator meet at area Nursing and CNA Schools and host job fairs. Interviews are done on the spot. Staffing needs for the day are assessed daily and evaluated if the Nursing Management (Unit Managers, ADON, and Facility Educator) needs to assist with resident care. Staff recognition is done monthly, a monthly incentive is offered for staff that do not call out. Elmwood Hills established a recruitment and retention committee. Elmwood Hills hired a recruitment and retention employee. Elmwood Hills does weekly Orientation. Elmwood Hills uses multiple employment search engines and multiple social media platforms. Elmwood Hills does recruitment events at area CNA schools; interviews are done on the spot at the area schools. In addition, two employees are on the Camden County College Advisory Committee and encourage new students and graduating students to apply at Elmwood Hills. Elmwood Hills continues to offer flexible schedules to staff. Alert and Oriented residents will be interviewed regarding the timeliness of staff response when requesting help as part of their Quarterly care conference meetings. This date will be reported to Social Services quarterly to the QA Committee for the next two meetings, which will evaluate that the deficiency remains corrected and in compliance with regulatory requirements. IV. Corrective Action will be monitored to ensure the deficient practice will not recur: The Director of Nursing (DON)/Designee will conduct daily Certified Nursing (CNA) staffing schedule audits for the next six months. The DON/designee will report audit findings to the Administrator for analysis, tracking and trending. The Administrator will report on the findings of the Certified Nursing Assistant staffing audits to the Quality Assessment and Assurance (QAA) Committee for the next two quarters. The QAA committee will determine the need for any additional monitoring of Certified Nursing Assistant staffing after the 2nd quarterly meeting. V. Date of Compliance: 1/17/25