Nurse Staffing Deficiency Identified
Penalty
Summary
The facility failed to meet the mandatory nurse staffing requirements as outlined in N.J.A.C. 8:39-25.2(b)(1)&(2) for two days during the weeks of 12/08/2024 and 12/21/2024. Specifically, on 12/08/2024, the facility provided 240 actual staffing hours, falling short by 2.25 hours from the required 242.25 hours. Similarly, on 12/15/2024, the facility provided 240 actual staffing hours, which was 4 hours less than the required 244 hours. This deficiency was identified based on the review of Nurse Staffing Reports and was associated with complaint numbers NJ00168416 and NJ00181485.
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.