Failure to Update Facility-Wide Assessment and Resource Planning
Penalty
Summary
Facility staff failed to update the Facility-Wide Assessment, which is required to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment tool, last dated 9/13/24, was missing critical information, including the names of persons involved in completing the assessment, dates of review with the QAA/QAPI committee, and accurate data on resident census, acuity levels, special treatments, ADL assistance needs, mobility, and the average daily staffing plan. These omissions meant the assessment did not accurately reflect the facility's current resident population or resource needs. Interviews with the DON and interim administrator revealed confusion regarding responsibilities for updating the assessment and the frequency with which updates should occur. The DON believed the administrator was responsible for updating the census and was unsure if the administrator knew how often the assessment should be updated. The interim administrator confirmed that the assessment should be updated annually and as needed, such as with changes in administration, DON, staffing requirements, resident acuity, or census, but could not explain why this had not been done.