Inaccurate Facility Assessment for Direct Care Staffing Ratios
Penalty
Summary
The facility failed to provide an accurate and comprehensive facility-wide assessment regarding direct care staff to resident ratios. During the survey, the administrator provided a copy of the facility assessment, which was found to have been completed and reviewed by the quality assurance committee. Upon review, the assessment included a staffing template for both licensed nurses and direct care staff, separated by skilled rehab and long-term care units. When questioned, the administrator was unable to explain the staffing plan as described in the assessment and later admitted that the staffing plan documented was incorrect. The administrator then provided a hand-written staffing to resident ratio for all units, but this information did not match the ratios documented in the facility's assessment. This discrepancy between the documented staffing plan and the actual staffing ratios, as well as the administrator's inability to explain or reconcile the information, led to the determination that the facility failed to provide an accurate facility assessment for direct care staff to resident ratios.