Failure to Meet CNA 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 a minimum of one Certified Nurse Aide (CNA) for every eight residents during the day shift. This deficiency was identified during a review of staffing records for the period from November 24, 2024, to December 7, 2024. During this time, the facility was consistently understaffed on 13 out of 14-day shifts, with the number of CNAs falling short of the required number needed to adequately care for the residents. For instance, on November 24, 2024, the facility had 14 CNAs for 143 residents, whereas at least 18 CNAs were required. Similar deficiencies were noted on other days, such as November 25, 2024, with 13 CNAs for 143 residents, and December 2, 2024, with 12 CNAs for 134 residents. This pattern of insufficient staffing was observed throughout the reviewed period, indicating a systemic issue in maintaining the mandated staffing levels, which had the potential to affect all residents in the facility.
Plan Of Correction
No residents were identified. Residents of the facility have the potential to be affected. The Director of Nursing, Staffing Coordinator, and Administrator will meet daily during the week to review recruitment efforts, staffing for the next day, and staffing for the upcoming week. The facility has developed a Culture Committee focused on recruitment and retention of staff along with customer service and the employee experience. The facility has implemented the Care Champion Program to mentor new employees, which has been proven to raise retention rates. The facility participates in an interdisciplinary Quality Care Resource call to review open positions, recruitment tactics, and changes to improve outcomes. The facility has implemented a multifaceted approach for recruitment and retention of employees, including job fairs, flexible scheduling, increased utilization of PRN staff, implementation of OnShift, multimedia advertisements, partnership with schools, sign-on bonuses, referral bonuses, pick-up shift bonuses, a boomerang campaign to rehire staff that have resigned, rate adjustments, benefit adjustments, contract staff utilization, and text message campaigns. An ongoing staffing analysis is reviewed by shift to determine the amount of direct care staff and licensed nursing staff required by regulatory requirements to meet the care needs of the residents based on the daily census. This analysis is used to ensure additional staff are scheduled to cover call outs. Vacancy and retention rates are analyzed weekly by the DON and Staffing Coordinator to identify additional hiring to ensure care needs and regulatory requirements are met. The staffing schedule was reviewed by the DON, DON consultant, Administrator, and the Staffing Coordinator to identify by shift the required number of direct care and licensed nursing staff based on current and projected census. Innovative scheduling is being used to ensure adequate licensed nursing staff meet the regulatory requirements and resident care needs based on acuities. The facility has agreements with CNA programs/schools to utilize the facility as a clinical site for their students. A QAPI root cause analysis was conducted, including direct care and licensed nurses from all shifts, to identify internal and external barriers to attract new staff. Assignments were reviewed to assure residents with high acuities are equally distributed on direct care staff assignments. Performance evaluations are completed, and targeted education is provided to staff to ensure they feel competent in their role to enhance job satisfaction. Job applications are readily available at the reception desk to ensure individuals looking for a job can be provided with an application immediately, and an interview can be coordinated that same day to expedite hiring. The administrator/designee will review the minutes from the resident council to determine whether any concerns regarding care and services are identified monthly for two months and then quarterly. The results of Resident Council minutes, as well as recruitment data, will be reviewed by the Administrator or designee at the quarterly QAPI meeting. These audits will be conducted weekly for 4 weeks, then monthly for 2 months. The findings of the audits will be submitted by the Administrator to the QAPI Committee for review and recommendation monthly for 3 months or ongoing until compliance is sustained.