Inadequate Facility Assessment for Resident Needs
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment using evidence-based methods to identify the specific resources necessary to care for its resident population. The assessment did not accurately reflect the needs and services required by the various subsets and characteristics of the resident population, including those with Alzheimer's, dementia, and behavioral health needs. The facility's assessment was not updated to include critical factors such as specific staff competencies, equipment needs, and services required to meet the individual and collective needs of the residents. The review of the facility's Resident Matrix revealed a total census of 98 residents, with 46 residents diagnosed with Alzheimer's or dementia and 26 residents receiving psychiatric and/or psychological services. Despite these characteristics, the facility assessment presented to the survey team indicated there were no residents with behavioral health needs requiring special treatments and conditions. This oversight failed to ensure resident safety and did not accurately reflect the current population's needs. Additionally, the facility assessment did not include the necessary resources, such as the overall number of facility staff, including dietary and activity staff, and contracted staff like agency nursing staff. It also failed to evaluate the physical resources needed, including resident care equipment, medical supplies, and non-medical supplies, to provide the required care and services. During an interview, the Nursing Home Administrator acknowledged that the Facility Assessment did not contain all the required information needed to meet regulatory requirements and address the specific needs of the resident population.
Plan Of Correction
The facility cannot retroactively correct the deficiency cited by the surveyors. The facility assessment will be updated to contain all the required information needed to meet regulatory requirements and address the specific needs of the resident population. The facility recognizes that all residents have the potential to be affected by the noted practice. See section 3 and 4 for system changes and monitoring. The Nursing Home Administrator will continue to review and update the facility assessment quarterly as required and make changes as needed. The assessment will be reviewed at the quarterly Quality Assurance with the Interdisciplinary team for any recommendations.