Deficient Staffing Ratios in Day Shifts
Penalty
Summary
The facility failed to meet the mandatory staffing ratios as required by New Jersey state law, specifically during the day shifts over a three-week period from December 1, 2024, to December 21, 2024. The deficiency was identified in 9 out of 21 day shifts, where the number of Certified Nurse Aides (CNAs) was insufficient to meet the mandated ratio of one CNA to every eight residents. This staffing shortfall was documented in several instances, with the number of CNAs ranging from 6 to 9, while the required number was at least 10 for the resident population during those shifts. The specific dates and staffing levels were as follows: On December 1, 4, 8, 9, 13, 14, 15, 16, and 21, the facility had fewer CNAs than required for the number of residents present. For example, on December 1, there were 7 CNAs for 79 residents, and on December 15, there were only 6 CNAs for 83 residents. These instances demonstrate a consistent failure to comply with the staffing requirements, which are crucial for ensuring adequate care and supervision of residents.
Plan Of Correction
1) How the corrective action will be accomplished for those residents found to have been affected by the deficient practice: The facility leadership team has met on an ongoing basis and continued to identify staffing challenges and areas of improvement for licenses and certified staffing needs. 2) How the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this practice. 3) What measures will be put into place or systemic changes will be made to ensure that the deficient practice will not recur: The DON conducted an audit of staffing schedules with the current facility census to ensure fulfillment of staffing requirements per shift. The facility has implemented an incentive program including referral bonuses for employees referring staff where appropriate, conducted job fairs, immediate interviews with contingency offers, and expedited the onboarding process of new hires. The facility has contracted a vendor with agency staff as needed to meet staffing needs. The Director of Nursing and Director of Rehabilitation continue to partner in addressing staffing challenges. Where appropriate, the occupational therapy staff assist in providing care and activities of daily living to residents. 4) How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e. what QA program will be put into place to monitor the continued effectiveness of the systemic change: The DON and/or designee will meet with the staffing coordinator daily to review facility census, call outs if any, and staffing needs. The DON and/or designee will monitor callouts and staffing ratios weekly until the requirement is met. The results of the audits will be forwarded to the facility Administrator and QAPI Committee for further review and recommendations as needed.