Facility Assessment Lacked Comprehensive Staffing and Resource Evaluation
Penalty
Summary
The facility failed to update its Facility Assessment to include a comprehensive evaluation of the resident population and the necessary resources, such as staffing levels and competencies, required to meet resident needs during both routine operations and emergencies. Review of the facility's policy indicated that the assessment should be conducted annually and used to inform staffing decisions for all shifts, including nights and weekends, and should be adjusted based on changes in the resident population. However, the Facility Assessment document only marked sufficiency analysis categories as 'Evaluated' without documenting specific staffing levels for each shift or addressing the specific skills and competencies needed for the current resident population. During an interview, the Administrator confirmed that the assessment process involved marking staffing as 'evaluated' or 'sufficient' without actually calculating or addressing the staffing and skills required for specific shifts, including night shifts, weekends, and emergencies. This lack of detailed documentation and analysis was observed over three survey days, and the deficiency was identified through interviews, record reviews, and policy reviews. No specific residents or their medical conditions were mentioned in relation to this deficiency.