Incomplete Facility-Wide Assessment and Staffing Documentation
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 and emergencies. The assessment did not address required staffing ratios per shift, the need for a Registered Nurse (RN) for at least eight consecutive hours daily, or the designation of an RN as the Director of Nursing (DON). Additionally, the assessment lacked documentation regarding the ratios of direct care staff, restorative therapy staff, social services staff, dietary staff, housekeeping, and laundry staff needed on each shift to meet resident needs. There was also no information provided about staff competencies and skill sets required to care for the resident population. The facility's policies and admission agreements indicated that it serves residents with skilled nursing needs, including those with Alzheimer's disease, dementia, and other complex medical and behavioral conditions. The facility's resident matrix showed a diverse population with diagnoses such as Alzheimer's/dementia, hospice care, dialysis, intravenous therapy, PTSD/trauma, and various medication requirements, including insulin, anticoagulants, antianxiety, antipsychotic, antidepressant, and hypnotic medications. Despite these complex care needs, the facility did not have a full-time DON or a full-time social worker or social service designee at the time of the survey. During the survey, the administrator acknowledged responsibility for completing the facility assessment but stated that it was incomplete due to missing maintenance and nursing information. The only documented information in the assessment pertained to contact information for external resources or when to use another facility, rather than a thorough evaluation of internal resources and staffing. As a result, the facility did not have a complete or thorough facility-wide assessment as required.