Incomplete Facility Assessment Omits Staffing and Behavioral Health Needs
Penalty
Summary
The facility failed to ensure its facility-wide assessment included all necessary resources to competently care for residents during both routine operations and emergencies. The assessment provided was undated and unsigned, lacking documentation of review or approval by the Quality Assurance and Performance Improvement (QAPI) committee. It did not specify minimum staffing requirements for Certified Nurse Aides (CNAs) and Licensed Practical Nurses (LPNs) on weekends, nor did it address the number of staff needed for behavioral healthcare services. The assessment also omitted information on staffing for emergencies and did not include signatures from staff involved in its creation or review. Observations and interviews revealed that staff and residents experienced the effects of inadequate staffing. A CNA reported frequent short staffing, making it difficult to provide adequate care to all residents. A resident described extended wait times for call bell responses, sometimes up to 2.5 hours, and noted that responses varied depending on which staff were on duty. The resident also reported being told they had behavioral issues when voicing concerns and that administration became upset when calls were escalated. The administrator acknowledged that the facility assessment did not reflect weekend staffing needs or behavioral health services and was unaware of recent changes in staffing regulations.