Failure to Meet Mandatory CNA Staffing Ratios on Day Shifts
Penalty
Summary
The facility failed to meet mandatory staffing ratios for Certified Nurse Aides (CNAs) on all 14 day shifts reviewed during the period from 03/23/25 to 04/05/25. According to the New Jersey Department of Health requirements, the facility was required to have one CNA for every eight residents during the day shift. However, staffing records showed that the number of CNAs present each day was consistently below the required minimum, with the facility having between 15 and 18 CNAs for 187 to 192 residents, when at least 23 to 24 CNAs were needed per shift. This deficiency was identified during a review of facility documents in response to complaints NJ182091 and NJ185153. The deficient practice had the potential to affect all residents in the facility, as the staffing shortfall occurred on every day shift reviewed within the two-week period. The report references state law and regulations that specify the minimum staffing requirements and details the exact shortfall for each day, but does not provide information about specific residents or their medical conditions at the time of the deficiency.
Plan Of Correction
S560 Mandatory Access to Care 1. Corrective Action - Staffing coordinator as educated on New Jersey state staffing ratio requirements by the DON on May 19, 2025. - Efforts to hire facility staff will continue until there is adequate staff to meet the minimum staff to resident ratios. Until that time, the facility will use staffing agencies and offer additional shifts to current staff with bonuses as required. 2. Identification of other residents or areas having the potential to be affected due to the nature of the deficiency: - All residents have the potential to be affected by this deficient practice. 3. Measure Put into Place: - Weekly recruitment, retention and employee appreciation meeting was initiated and will be led by the Director of Human Resources and/or designee. - Hiring and recruitment efforts including pay for experience, online job listing, job fairs, shift differentials and referral bonuses are being utilized to continue to be competitive in the marketplace. - The facility administrator/designee will continue to track and document any recruitment and retention efforts weekly. - The administrator, DON/designee will review staffing schedules weekly to ensure adequate staffing for all shifts. 4. How Will These Actions Be Measured: - The results of the weekly recruitment and retention audits will be submitted to the Quality Assurance and Process Improvement Committee Meeting monthly for 6 months. Based on the results of these audits, a decision will be made regarding the need for continued submission and reporting. The next Quality Assurance and Process Improvement Committee Meeting will be held on June 6, 2025.