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 the state of New Jersey. This deficiency was identified through observation, interviews, and review of facility documentation, and was evidenced by multiple instances where the number of Certified Nurse Aides (CNAs) scheduled for the day shift was below the minimum required for the census. The deficiency was found on 43 of 49 day shifts and 4 of 49 overnight shifts reviewed across several complaint periods, with specific examples provided for each period showing the number of CNAs present versus the number required by law. Interviews with the Staffing Coordinator, DON, and LNHA confirmed their awareness of the state-mandated ratios (1:8 for day shift, 1:10 for evening, and 1:14 for night), but also revealed that the facility did not always meet these requirements. The Staffing Coordinator stated that when there was a shortfall, other staff members who were also CNAs, such as the Staffing Coordinator, Unit Clerks, or Recruiter, would provide resident care. Despite these efforts, the documented staffing levels on numerous shifts did not meet the minimum ratios. A review of the facility's own Nursing Staffing Policy, revised in January 2025, reiterated the commitment to adhere to state staffing standards and outlined the required CNA ratios. However, the documented staffing schedules for multiple weeks showed consistent shortfalls in CNA coverage, particularly on the day shift, and occasional deficiencies in total staff on overnight shifts. No specific residents or patient conditions were mentioned in relation to the deficiency.
Plan Of Correction
I. Corrective Action Accomplished for Resident(s) Affected: Director of Nursing/Designee meets daily and before weekends with a staffing coordinator to review staff sufficiency to ensure minimum staffing hours requirement is met along with extra hours needed to meet special services need of our residents as required at N.J.A.C 8:39-25.1. Staffing coordinators will send daily emails with the staffing number to the Administrator and Director of Nursing and ADONs and Nursing Supervisor. II. Residents identified having the potential to be affected and corrective action taken: All residents residing in the facility had the potential to be affected. A random sample of twenty alert and oriented residents were interviewed regarding staff response times to requests for assistance with concerns reported to the Director of Nursing for rectification. III. Measures to be put in place to ensure the deficient practice will not recur: The Call Out Policy was reviewed by the facility administration and staff have been reeducated by the Facility Educator on the policy. Referral and Sign-on Bonuses are offered for both Licensed and Certified Nursing Staff. The Retention and Recruitment Coordinator and Nurse Educator meet at area Nursing and CNA Schools and host job fairs. Interviews are done on the spot. Staffing needs for the day are assessed daily and evaluated if the Nursing Management (Unit Managers, ADON, and Facility Educator) needs to assist with resident care. Staff recognition is done monthly, a monthly incentive is offered for staff that do not call out. Elmwood Hills established a recruitment and retention committee. Elmwood Hills hired a recruitment and retention employee. Elmwood Hills does weekly Orientation. Elmwood Hills uses multiple employment search engines and multiple social media platforms. Elmwood Hills does recruitment events at area CNA schools; interviews are done on the spot. Elmwood Hills continues to offer flexible schedules to staff. Alert and Oriented residents will be interviewed regarding the timeliness of staff response when requesting help as part of their Quarterly care conference meetings. This date will be reported to Social Services quarterly to the QA Committee for the next two meetings, which will evaluate that the deficiency remains corrected and in compliance with regulatory requirements. IV. Corrective Action will be monitored to ensure the deficient practice will not recur: The Director of Nursing (DON)/Designee will conduct daily Certified Nursing Assistant (CNA) staffing schedule audits for the next six months. The DON/designee will report audit findings to the Administrator for analysis, tracking, and trending. The Administrator will report the findings of the Certified Nursing Assistant staffing audits to the Quality Assessment and Assurance (QAA) Committee for the next two quarters. The QAA committee will determine the need for any additional monitoring of Certified Nursing Assistant staffing after the 2nd quarterly meeting. V. Date of Compliance: 6/22/25