Failure to Meet Mandatory CNA Staffing Ratios on Day Shifts
Penalty
Summary
The facility failed to comply with 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. During a review of facility documents covering a two-week period prior to the complaint survey, it was found that the facility did not meet the required CNA staffing levels on 12 out of 14 day shifts. For example, on several days, the number of CNAs scheduled was significantly below the minimum required, with as few as 6 CNAs present for 100 residents when at least 12 were needed, and similar shortfalls on other days for varying resident counts. This deficiency was identified through a review of staffing records and was determined to have the potential to affect all residents in the facility. The report does not specify individual residents or their medical conditions but notes that the deficient practice was widespread across multiple days and shifts, impacting the facility's ability to meet the mandated standard of care for its resident population.
Plan Of Correction
Plan of Correction Root Cause: Upon review of the S560 tag, the facility noted the root cause of this issue to be because the facility failed to ensure that all call outs were covered. S560 Immediate Corrective Action: The Facility cannot retroactively respond to this deficient practice. On 4/25/2025, the Administrator, Human Resource Director/Staffing Coordinator, and Director of Nursing conducted a root cause analysis based on the findings in the alleged deficient to ensure that the facility provides sufficient nursing staff to promote the highest practical wellbeing of each resident. On 4/25/2025, the Administrator/Designee conducted in-services and education with the staffing coordinator and nurse management team on the facility's policy and procedure for sufficient nurse staffing, with specific emphasis on the facility's protocol for emergency staffing. Identification of Others: An assessment of the risk this deficient practice could have on residents at this facility was completed by the administrator, Director of Nursing, Staffing Coordinator, HR Manager, and it was found that all residents were impacted by this deficient practice. III. Systemic Change: The Facility Director of Nursing, Administrator, HR Manager initiated the following employee recruitment programs for the clinical department: - Rates increased - Offer our staff bonuses - Job Fair - Posting new ads around town and via social media - Staff Testimonial videos for recruitment - Referral bonuses for our staff - Referral bonuses relationship with local CNA school to provide additional staffing support - Sign on bonus IV. The Human Resources Director/Designee will report the findings to the administrator. V. Quality Assurance: The Human Resources Director/Designee will aggregate findings from these rounds weekly for 1 month and then monthly for 3 months. The Human Resources Director/Designee will provide a report of his/her findings to the QA committee for action as appropriate. The QA/QAPI committee will meet monthly for the next 3 months and review all findings to assess whether further action is necessary.