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 a review of staffing reports and interviews, revealing that on multiple occasions, the number of Certified Nurse Aides (CNAs) scheduled for the day shift did not meet the statutory requirement of one CNA for every eight residents. Specific instances were documented where the facility was short by one or more CNAs on various day shifts, with similar deficiencies noted for the evening shift on at least one occasion. The surveyor's review of facility documentation, including the "Nursing Staffing Report" and the facility's "Sufficient Staffing Policy," confirmed that the facility was aware of the minimum staffing requirements. Despite this, the facility's own records showed repeated non-compliance across several weeks, with as many as six out of seven day shifts in some weeks falling below the required CNA-to-resident ratio. The Scheduling Coordinator and the Licensed Nursing Home Administrator both acknowledged familiarity with the staffing requirements and reported efforts to meet them, such as using agency staff and offering bonuses, but the documented staffing levels did not consistently meet the mandated ratios. No specific residents or patient medical histories were detailed in the report, and the deficiency was identified based on staffing numbers and scheduling practices rather than individual resident outcomes. The findings were based on a combination of interviews with facility staff and a review of staffing schedules over multiple weeks, demonstrating a pattern of insufficient CNA staffing during the day shift.
Plan Of Correction
The facility actively seeks to hire CNAs, that all shifts are scheduled to comply with ratios, that any callouts or no-shows result in calls being made by the Staffing Coordinator or the shift Supervisor to fill the shift. The facility has documented evidence to reflect recruitment and retention efforts in its relentless attempts to comply with the staffing ratios. All residents have the potential to be affected. Staffing Coordinator was re-educated by the Administrator on current staffing regulation and shift ratios. Recruitment and retention efforts continue to include: a. Daily staffing meetings and weekly Regional Labor Management reviews b. Training mentor program to support retention c. Employee Enrichment committee in place to improve and maintain staff morale d. Recruitment bonus and sign-on bonuses offered e. Competitive wage analysis DON/Staffing Coordinator/Administrator or designee will monitor and review staffing daily for 1 week, weekly for 3 weeks, and monthly for 3 months. Results will be presented to the Quality Assurance and Performance Improvement (QAPI) team monthly for continued review and recommendations until substantial compliance is maintained.