Incomplete and Inaccurate Facility Assessment with Missing Critical Resource Information
Penalty
Summary
The facility failed to develop a complete and accurate facility-wide assessment, as required, to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment lacked identification of required participants, was not reviewed with the QAPI committee, and contained numerous blank sections regarding essential services such as laboratory, x-ray, food, laundry, contracted services, and staff scheduling. Additionally, the certified bed capacity was incorrectly listed, and critical information regarding wound care, food service practices, spiritual programs, behavioral health, ancillary services, and staff schedules was missing. The staffing plan did not address the number of direct care staff needed for each shift or provide details on staff assignments, and the section on contracts and emergency preparedness was incomplete. Interviews with facility leadership revealed inconsistencies and lack of involvement in the assessment process. The Administrator initially stated she had no involvement in the assessment revision and could not identify the corporate staff member who completed it, but later claimed to have completed it herself with input from the DON, who denied participating. The DON also confirmed the presence of missing and incorrect information in the assessment. These deficiencies had the potential to affect all 64 residents in the facility.