Failure to Conduct Comprehensive Facility-Wide Resource Assessment
Penalty
Summary
The facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during both day-to-day operations and emergencies. The assessment provided by administrative staff was updated annually and identified required staffing needs per day, but did not specify staffing needs for day, night, and weekend shifts. Review of the facility's Payroll Based Journaling (PBJ) data revealed excessively low weekend staffing in all four quarters reviewed. Additionally, administrative staff confirmed that the assessment did not separate required hours by shift, only showing total required hours. The facility's policy required a documented assessment to determine necessary resources for resident care during daily operations, but this was not fully implemented.