Incomplete Facility Assessment and Resource Planning
Penalty
Summary
The facility failed to complete a thorough and accurate facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment lacked input from residents, resident family members, and direct care staff. Additionally, it did not specify staffing needs by shift and unit, nor did it include a plan for staff recruitment and retention. There was also no contingency planning for events that could affect resident care but do not require activation of the emergency plan, such as nurse staffing shortages. Several required sections of the assessment, including those addressing medical practitioner recruitment, staff familiarity with standards of care, inventory management, health information technology, and infection prevention and control, were left blank or incomplete. The administrator confirmed that the assessment was completed only with input from select facility leadership and the governing body, without broader stakeholder involvement. The administrator also acknowledged the absence of a contingency staffing plan and recruitment/retention system in the assessment, and stated that certain sections were left blank because they were believed to be non-mandatory. The facility census at the time documented 93 residents who could potentially be affected by these deficiencies in the facility assessment process.