Failure to Assess and Provide Necessary Resources and Competencies for Resident Care
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment did not adequately address sufficient staffing, educational resources, or a competency-based approach for staff training and evaluation. Specifically, the facility did not identify or document the competencies required upon orientation or annually, nor did it ensure that staff had the knowledge and skills necessary to maintain or improve residents' physical, functional, mental, and psychosocial well-being in accordance with professional standards of practice. The facility also failed to implement an effective infection control surveillance plan for identifying, tracking, monitoring, and reporting infections, communicable diseases, and outbreaks among residents and staff. Interviews with facility leadership revealed that required staff training and clinical competencies had not been completed or documented, and that the DON, who was covering the roles of infection preventionist and educator, lacked the necessary specialized training in infection prevention and control. The facility did not have a designated or qualified infection preventionist, nor did it employ an Assistant Director or Staff Educator to manage staff competencies. Staffing shortages were also noted, and the Administrator was unaware of the specific competencies required for clinical staff, further contributing to the deficiency.