Inaccurate Facility Assessment Leads to Inadequate Staffing for Resident Care
Penalty
Summary
The facility failed to conduct an accurate and thorough facility-wide assessment to determine the necessary resources required to care for residents competently during both routine operations and emergencies, including nights and weekends. Review of resident data revealed that the number of residents dependent on staff for activities of daily living (ADLs) such as toileting, dressing, bathing, and transferring significantly exceeded the facility's stated capacity in its assessment. Specifically, there were 15 residents dependent on staff for toileting, 14 for dressing, 14 for bathing, and 9 for transferring, while the facility assessment only accounted for the ability to care for five residents in each of these categories. Additionally, the assessment outlined staffing requirements that were not met, including the need for four full-time RNs, four full-time LPNs, and fourteen full-time CNAs, while actual staffing levels were lower in several categories. Interviews with the Director of Nursing (DON), Facility Administrator, and Dietary Director confirmed discrepancies between the facility assessment and actual staffing levels, including insufficient numbers of direct care and dietary staff to meet the needs of the current resident population. The DON and Facility Administrator acknowledged that the facility-wide assessment was not completed accurately, resulting in inadequate staffing to provide timely and quality care for residents. This deficiency was identified during a complaint investigation and had the potential to affect all residents in the facility.