Inaccurate Facility Assessment and Documentation Failures
Penalty
Summary
The facility failed to complete an accurate and comprehensive facility-wide assessment, which is required to determine the necessary resources to care for residents competently during both routine operations and emergencies. The assessment contained multiple inaccuracies, such as listing incorrect numbers of residents with specific conditions, referencing another facility's name and data, and including staffing and population details that did not match the actual facility. Additionally, the assessment did not document the names of staff, residents, or family members who participated in its development, and omitted required information about recruitment, retention, contingency staffing plans, and QAPI training. During interviews, facility leadership acknowledged the involvement of the interdisciplinary team in developing the assessment but could not explain the presence of erroneous data or references to another facility. The Assistant Administrator and Nurse Consultant confirmed there was no other facility assessment available and could not account for the discrepancies. The facility's policy requires an annual review and documentation of a facility-wide assessment, but the provided assessment did not meet these requirements, potentially affecting all 127 residents residing in the facility.