Incomplete Facility Assessment Omits Pediatric Equipment and EHR Implementation
Penalty
Summary
The facility failed to maintain an accurate and up-to-date facility-wide assessment regarding the resources necessary to care for its resident population, specifically omitting critical equipment and technology updates. The assessment did not reflect the use of pediatric shower beds and other pediatric-specific bathing equipment, despite the presence of 33 pediatric residents in the facility. Interviews with the Administrator and Director of Nursing revealed that the facility assessment only listed shower chairs, and did not include pediatric shower beds or gurneys, even though these were in use or had been requested by staff. The omission was confirmed during multiple record reviews and staff interviews, with the DON acknowledging that the assessment was incomplete and missing essential equipment details for the pediatric population. Additionally, the facility assessment failed to accurately document the transition to electronic health records (EHR). Although the facility began using EHR on April 1, 2025, the assessment continued to state that medical records were paper documents and only referenced a future transition to EHR. Both the Administrator and Staff Development Coordinator confirmed in interviews that the assessment was not updated to reflect the current use of EHR, and the DON also stated that the assessment was not complete or accurate in this regard. These deficiencies were identified through interviews and record reviews, which demonstrated that the facility's assessment did not accurately represent the resources and technology in use. The lack of accurate documentation in the facility assessment had the potential to delay necessary care and services for residents, particularly for the pediatric population and in the management of health information technology.