Failure to Conduct Comprehensive Facility Assessment and Staffing Evaluation
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment as required by its own policy and regulatory standards. The assessment did not include a thorough evaluation of available staffing, staff competencies, or training, nor did it incorporate a community-based risk analysis to identify potential natural disasters and their impact on residents and operations. The facility also did not formulate a plan for staff recruitment or retention to meet resident needs, and the assessment lacked up-to-date information on staffing needs by shift, relying instead on outdated ratios and an incomplete addendum that did not specify actual staffing requirements. A review of the facility's assessment profile revealed that while intravenous (IV) therapy was provided as a nursing service, there was no documented plan for education or training of LPNs in IV medication administration or care of specialized IV access devices. The facility did not assess or reassess nurse qualifications to ensure they could meet the identified nursing services. Additionally, the facility did not conduct a self-assessment to identify potential natural disasters or analyze their impact on residents, staff availability, utilities, or supplies, instead referring to a separate emergency preparedness binder that was not integrated into the facility assessment process. Interviews with staff indicated significant gaps in leadership and staffing. The facility was operating without a DON, and the ADON, who was also the Infection Preventionist, was unable to assume DON duties due to bedside responsibilities. The Medical Records Nurse reported being unable to perform her primary duties for an extended period due to working on the floor. These staffing challenges were not addressed in the facility assessment, and there was no outlined plan for recruitment or retention of staff to fill critical roles.