Incomplete Facility-Wide Assessment and Documentation Deficiencies
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, including nights and weekends, and emergencies. The assessment did not address what constitutes sufficient staffing, particularly on weekends, nor did it differentiate the care required on weekend shifts from other shifts. Additionally, the assessment lacked information on the number of staff needed for behavioral health services and did not specify the minimum staffing requirements for Certified Nurses' Aides (CNAs) and Licensed Practical Nurses (LPNs). The assessment also omitted the date it was reviewed with the Quality Assurance and Performance Improvement (QAPI) committee and lacked signatures of approval. During interviews, the Administrator acknowledged that the facility assessment did not include the exact number of CNAs or LPNs required, citing frequent staffing changes and reliance on Payroll-Based Journal (PBJ) reports for staffing information. The Administrator was unable to provide documentation that the assessment was reviewed by QAPI and agreed that the assessment should have been signed and dated. The deficiencies were identified through record review and staff interviews during abbreviated surveys, with the most recent revisions of the facility assessment still lacking required details and documentation.