Facility Fails to Conduct Comprehensive Assessment and Ensure Qualified Dietitian On-Site
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources to care for its residents competently during both day-to-day operations and emergencies. The assessment did not include specific information about the facility's population, the resources required, or the current staff employed to ensure a sufficient and competent number of qualified staff are available to meet each resident's needs. The Centers for Medicare and Medicaid Services Memorandum requires that the facility assessment include an evaluation of diseases, conditions, and limitations of the resident population, which should inform staffing decisions and the skills and competencies staff must possess. The review of the facility's Resident Matrix identified a resident receiving enteral feeding who would require the services of a qualified dietitian. However, the facility's full-time foodservice director, who is a Certified Dietary Manager, does not meet the qualifications to be a qualified dietitian. The facility employs a part-time registered dietitian who works remotely, completing nutritional assessments and progress notes offsite without face-to-face interaction with residents. This lack of a comprehensive assessment and the absence of a qualified dietitian on-site have the potential to negatively affect the quality of care and quality of life for all residents.
Plan Of Correction
1. The Facility Assessment was updated to reflect the current resident population and needs. 2. The Facility Assessment will be reviewed at least quarterly and PRN. 3. The facility's IDT were re-educated on completion of the Facility Assessment to accurately reflect the current resident population and needs. The NHA will ensure regular updates. 4. The NHA will conduct an audit of the Facility Assessment monthly x 6 months to ensure accuracy. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.