Failure to Maintain Minimum CNA Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by New Jersey law. Specifically, during several reviewed periods, the number of Certified Nurse Aides (CNAs) scheduled for the day shift did not meet the minimum ratios required for the number of residents present. For example, on multiple occasions, the facility was short by one or two CNAs compared to the required staffing levels for the number of residents on the day shift. These deficiencies were identified through a review of staffing records for specific weeks in January, July, March, and April, where the number of CNAs fell below the mandated ratios on certain days. Interviews with the Staffing Coordinator and the Director of Nursing confirmed awareness of the staffing requirements and acknowledged the facility's challenges in meeting them, particularly on weekends. The facility did not utilize agency staff and instead relied on internal staff, with managers and the Staffing Coordinator sometimes filling in as CNAs. The facility's policy stated that staffing numbers and skill requirements are determined by resident needs and care plans, but the documented staffing levels did not consistently meet the minimum legal requirements during the periods reviewed.
Plan Of Correction
The facility shall comply with applicable Federal, State, and local laws, rules, and regulations. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: No residents were identified nor immediately affected by the failure to provide minimum staffing levels as mandated by the State of New Jersey. 2. Address 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 deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Administrator was educated on S560 by Regional Director of Labor Management and Recruitment. Human Resources and Staffing Director was educated on S560 by the Administrator. Recruitment efforts continue to include: wage analysis and adjustments, vacant shift bonuses, online job listings, ongoing onsite job fairs, on-demand orientation classes, daily interviews to walk-ins, shift differentials, and referral bonuses. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: The Administrator or designee will review staffing schedules weekly to ensure adequate staffing for all shifts. Any findings will be followed up and documented and then reported during the quarterly QAPI meetings for one year's time, or until staffing levels are no longer an issue.