Incomplete Facility Assessment for Resident Care Needs
Penalty
Summary
The facility failed to implement and document a comprehensive facility-wide assessment that identified the specific resources necessary to care for its resident population. This deficiency was identified through a review of clinical records, staff interviews, and the facility's assessment documentation. The facility assessment, dated January 2025, did not include the use of a Life Vest, which is a condition requiring complex medical care and management that the facility routinely cares for. The deficiency was highlighted through the case of a resident admitted to the facility with diagnoses including alcoholic cardiomyopathy, sarcoidosis of the lung, and depression. The resident's nursing admission evaluation noted an irregular cardiac rate and the use of a Life Vest, a wearable defibrillator. A physician's order required daily checks and battery changes for the Life Vest, indicating the need for specific medical management. During an interview, the Nursing Home Administrator confirmed the facility's failure to conduct a complete facility-wide assessment that accounted for the specific medical needs of its residents, such as the use of a Life Vest. This oversight in the facility's assessment process led to the deficiency being cited.
Plan Of Correction
1. The facility assessment was reviewed by the administrative team. The words "aka life vest" were added to section 2.1 subsection Heart/circulatory system where "Presence of cardiac pacemaker / heart monitoring systems" was already listed. 2. The NHA will continue to review the facility assessment at least quarterly to ensure descriptors of facility are accurate to the care being provided in the facility.