Failure to Identify and Document Minimum Staffing Requirements in Facility Assessment
Penalty
Summary
The facility failed to review and update its facility-wide assessment to identify the minimum or baseline number of direct care and licensed staff required to meet residents' needs during both routine operations and emergencies. The assessment did not specify staffing hours per resident day (PPD) goals or the breakdown between licensed and direct care staff necessary to provide care based on residents' diagnoses, assessed needs, and comprehensive care plans. The assessment process described was fluid and based on daily evaluations by the nursing department and interdisciplinary team, but lacked concrete staffing numbers or ratios. The special memory care unit was noted to require special staffing considerations, but no specific minimums were documented. Interviews with staff revealed that daily staffing decisions were made based on the DON's direction and current census, with a general target of 3.3 to 3.4 PPD, but without a formalized or documented staffing plan in the facility assessment. The scheduler and DON both confirmed that the assessment did not identify the number or type of staff needed for each shift. Additionally, the facility assessment policy was requested but not provided. This deficiency had the potential to affect all 51 residents in the facility.