Failure to Conduct and Document Comprehensive Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive and accurate facility-wide assessment to determine the resources necessary to care for residents competently during both routine operations and emergencies. During a complaint survey, the facility provided a binder labeled as the facility assessment, but review of its contents revealed significant omissions and outdated information. The facility profile lacked current data, such as the average resident census and accurate staff information, and did not include the average number of staff on nights. Additionally, the profile listed contact information for previous administrators and maintenance directors, indicating it was not up to date. Further review showed that the assessment did not adequately evaluate the resident population's needs, including an analysis of diseases, conditions, physical and cognitive abilities, and overall acuity. The comorbidity report was limited to 50 residents and did not provide a comprehensive assessment of the entire population. The assessment also failed to address the specific care requirements for residents, such as the types of diseases and disabilities present, and did not evaluate the staff competencies necessary to meet these needs. There was no documentation of staff education, training, or health information technology resources relevant to the resident population. The facility assessment was also missing evaluations of the facility's physical resources, such as buildings, vehicles, equipment, and contracted services. There was no evidence of an assessment of ethnic, cultural, or religious factors that could affect care, nor was there documentation of an evaluation of the number of staff required to meet resident needs. The list of contracted providers did not include an evaluation of how these services would meet regulatory, operational, or training requirements. These deficiencies were acknowledged by the Nursing Home Administrator during the survey.