Incomplete Facility-Wide Assessment for Staffing and Resource Needs
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources required to care for its 20 residents competently during both routine operations and emergencies. The assessment provided did not specify the required staffing levels for each unit, nor did it detail the number of RNs, LPNs, CMAs, and CNAs needed based on patient acuity and census. Additionally, the assessment lacked information on staffing requirements for each shift, including evenings and weekends, and did not include contingency staffing plans for situations that could impact resident care but did not necessitate activation of the emergency plan. During interviews, administrative staff acknowledged that while some staffing information had been updated, the assessment did not include all required elements such as specific staffing levels, contingency staffing plans, or staff recruitment plans. The facility's own policy requires an annual evaluation of resident population and identification of necessary resources, including sufficient staff and appropriate competencies for all shifts, as well as contingency planning for events affecting resident care. However, the assessment reviewed did not meet these requirements, affecting all residents in the facility.