Deficiency in Mandatory Nurse Staffing Hours
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 1 out of 14 days during the review period. Specifically, on one day, the actual nursing staff hours provided were 208, which was 1.5 hours less than the required 209.5 hours based on the total number of residents and the acuity-based care hours needed for services such as wound care, tube feedings, oxygen therapy, tracheostomy, intravenous therapy, use of respirator, and advanced neuromuscular/orthopedic care. The deficiency was identified through a review of the Nurse Staffing Reports for the specified two-week period. During an interview, the Licensed Nursing Home Administrator (LNHA) acknowledged awareness of the minimum staffing ratio requirements and stated that the facility scheduled staff to meet those needs, utilizing bonuses and agency staff as needed. The facility's "Sufficient Staffing" policy, revised prior to the deficiency, required sufficient nursing staff with appropriate competencies to meet resident care needs on a 24-hour basis, including the designation of a registered nurse responsible for overseeing nursing activities on each shift. Despite these policies and efforts, the facility did not meet the required staffing hours on the identified day.
Plan Of Correction
The facility cannot retroactively correct the deficient practice. However, the facility seeks to schedule staff based on the required staffing level to comply with the State of NJ staffing requirements. All residents have the potential to be affected. The Administrator initiated an in-service with the Director of Nursing (DON) and Staffing Coordinator on ensuring that the required staffing levels are provided and also reviewed the Sufficient Staffing policy. The DON and Staffing Coordinator will complete daily staffing sheets to ensure that the facility is meeting the required staffing levels per regulations. The DON, Staffing Coordinator, Administrator and or designee will monitor and review the daily Staffing Acuity Work Sheets weekly x 4 weeks and then monthly x 3 months to ensure that the daily required staffing levels were met. The results will be presented to, will be reported, reviewed by the DON, Staffing Coordinator and or designee and submitted to the monthly Quality Assurance and Performance Improvement Committee (QAPI) for three (3) months in order to determine if further interventions are needed.