Failure to Meet Mandatory 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 2 out of 14 days during the review period. Specifically, on two separate days, the actual nursing staffing hours fell short of the required minimum hours calculated based on the total number of residents and the acuity of care needed, including services such as wound care, tube feedings, oxygen therapy, tracheostomy, intravenous therapy, respirator use, and advanced neuromuscular/orthopedic care. On one day, there was a deficit of 48.5 hours, and on another, a deficit of 15.75 hours compared to the required staffing levels. The deficiency was identified through a review of the Nursing Staffing Reports for the two weeks prior to the survey, which was conducted in response to specific complaints. The facility's contingency staffing plan, dated 8/1/24, was also reviewed and included provisions to ensure sufficient qualified staff to meet residents' needs based on assessments and care plans. However, despite this plan, the facility did not provide the minimum required nursing hours on the identified days.
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 the minimum staffing hours requirement is met along with the extra hours needed to meet the special services needs 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 (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 on 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