Failure to Conduct Comprehensive Facility Assessment for Staffing and Resource Needs
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment did not specify staffing requirements for day, evening, night, or weekend shifts based on the needs of the resident population. There was no documented plan for staff recruitment or retention, and the assessment team did not include direct care staff or resident representatives. The assessment relied on census numbers and minimal state requirements rather than a detailed analysis of resident acuity or specific care needs. Additionally, the assessment was not referenced by staff responsible for scheduling or staffing decisions. Interviews with facility leadership revealed a lack of understanding and utilization of the facility assessment in staffing and operational planning. The ADON and DON indicated that staffing decisions were based on corporate direction and minimal state formulas, without reference to the facility's own assessment. The Administrator also did not use the assessment to determine staffing needs, instead relying on general federal requirements. The facility's policy required a detailed review of resident acuity and available resources, but this was not reflected in the actual assessment or in practice.