Failure to Meet Minimum Nurse Staffing Requirements
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 three out of fourteen days, as evidenced by a review of Nurse Staffing Reports for the weeks of 04/06/25 and 04/19/25. Specifically, on three separate days, the actual nursing staff hours provided were below the required minimum, with deficits of 17.25, 14.75, and 6.75 hours respectively. The required staffing hours were calculated based on the total number of residents and the additional care needs of residents receiving specialized services such as wound care, tube feedings, oxygen therapy, tracheostomy, intravenous therapy, use of respirator, and advanced neuromuscular or orthopedic care. This deficiency was identified during the investigation of complaints NJ181841, NJ178109, and NJ182273.
Plan Of Correction
Plan of Correction Root Cause: Upon review of the S1680 tag, the facility noted the root cause of this issue to be because the facility failed to ensure that it was staffed at least minimum staffing ratio based on its acuities. S1680 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 nurse staffing based on the total number of residents multiplied by 2.5 + the facility's current acuities. On 4/25/2025, the Administrator coordinated with the Director of Nursing and Human Service Director a review of the facility policy and procedure for ensuring adequate nursing service ratios that meet the facility acuity needs. On 4/25/2025, the Administrator conducted an in-service with the Human Resources and Director of Nursing on the facility policy and procedure for ensuring adequate nursing service ratios that meet the facility acuity needs. 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, and Staffing Coordinator, HR Manager, and it was found that all residents were impacted by this deficient practice. Systemic Change: The Facility Director of Nursing, Administrator, HR Manager initiated the following employee recruitment programs for the clinical department: - Rates increased - Offering our staff bonuses - Job Fair - Posting new ads around town and via social media - Staff Testimonial videos for recruitment - Referral bonuses for our staff - Referring to bonuses relationship with local CNA school to provide additional staffing support - Sign on bonus The Facility Human Resource Director will conduct a daily review of staffing schedules based on facility census and acuities to ensure adequate staffing and report findings to the administrator. On 4/25/2025, the Administrator coordinated with the Director of Nursing and Human Service Director a review of the facility policy and procedure for ensuring adequate nursing service ratios that meet the facility acuity needs. On 4/25/2025, the Administrator conducted an in-service with the Human Resources and Director of Nursing on the facility policy and procedure for ensuring adequate nursing service ratios that meet the facility acuity needs. 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, and Staffing Coordinator, HR Manager, and it was found that all residents were impacted by this deficient practice. Systemic Change: The Facility Director of Nursing, Administrator, HR Manager initiated the following employee recruitment programs for the clinical department: - Rates increased - Offering our staff bonuses - Job Fair - Posting new ads around town and via social media - Staff Testimonial videos for recruitment - Referral bonuses for our staff - Referring to bonuses relationship with local CNA school to provide additional staffing support - Sign on bonus The Facility Human Resource Director will conduct a daily review of staffing schedules based on facility census and acuities to ensure adequate staffing and report findings to the administrator. V. Quality Assurance: The Human Resource Director/designee will aggregate findings from these rounds daily for 1 month and then monthly for 3 months and review the findings with the administrator and submit to QA/QA committee for review. The QA/QAPI committee will meet monthly for the next 3 months and review all findings to assess whether further action is necessary.