Failure to Assess and Provide Adequate Staffing and Equipment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the resources necessary to competently care for residents during both routine operations and emergencies. The facility's assessment did not include information regarding the number of staff required or the number of mechanical lifts needed to meet the needs of the resident population. Policy review indicated that the facility was required to assess equipment, supplies, and personnel annually, but the actual assessment lacked these critical details. The staffing policy also referenced the facility assessment as a basis for determining sufficient staffing, but this was not reflected in practice. Interviews with the Staff Development Coordinator (SDC) revealed that staffing was scheduled based on per patient day (PPD) calculations without consideration of resident acuity or specific care needs on different units. The SDC was unaware of the facility assessment's role in staffing decisions. Observations and interviews with the DON and Administrator confirmed that only one full-body lift and one sit-to-stand lift were available, and that if a lift was in use on one unit, residents on the other unit experienced delays in care. The Administrator acknowledged that the facility assessment did not address the number of lifts or staffing levels needed to provide timely care, affecting all residents, including those with higher dependency and diagnoses such as morbid obesity.