Inadequate Facility Assessment and Staffing Plan
Penalty
Summary
The facility failed to ensure that its facility-wide assessment was updated to accurately determine the resources necessary for competent resident care during daily operations. The assessment, which was supposed to guide staffing and resource allocation, was found to be outdated and incomplete. Specifically, it used acuity data from April 2023 to June 2023 to determine staffing needs, which did not reflect the current resident population or their care requirements. Additionally, the assessment did not specify the level of staff assistance required for residents' activities of daily living, nor did it include the educational requirements for all personnel or the contracts with third-party staffing agencies used to meet staffing needs. During an interview, the Administrator acknowledged responsibility for creating the Facility Assessment and determining the necessary staffing and equipment. However, the Administrator admitted that the staffing plan was based on the facility's goals rather than the actual number of staff required for day-to-day resident care. The facility had redefined its units, with the second floor no longer exclusively serving long-term residents due to an increase in short-term admissions. Despite working with a third-party staffing agency and using a computer application for scheduling, the facility's assessment and staffing plan did not adequately address the current operational needs.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 Immediate action(s) taken for the resident(s) found to have been affected include: - The Administrator reviewed and confirmed that acuity data captured in Quarter 2 of 2024 is included in the Facility Wide Assessment. - The Administrator reviewed and confirmed the Facility Wide Assessment includes education required by all personnel. Identification of other residents having the potential to be affected was accomplished by: - Residents residing within the nursing facility have the potential to be affected. Action taken/systemic change put into place to reduce the risk of future occurrence include: - The Administrator or designee will update the Facility Wide Assessment to include third-party staffing agency contracts by 3/31/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: - Administrator or designee will audit the Facility Assessment. Beginning on 4/1/25 audits will be monthly x6 months with a goal of 100% compliance. Findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Administrator