Failure to Maintain and Implement Comprehensive Facility-Wide Assessment for Staffing
Penalty
Summary
Facility staff failed to conduct and document a comprehensive, annual facility-wide assessment to determine the resources necessary to care for residents competently during day-to-day operations and emergencies. Review of the Facility Assessment Report dated July 2024 showed it did not contain required information on staffing for routine operations and emergency situations. The July 2024 assessment was identified as the only facility assessment available. The corporate director of finance, who was temporarily assisting at the facility after the abrupt departure of the previous administrator, stated not knowing how often the assessment needed to be updated or why the previous administrator had not maintained it. Interviews further showed that staffing practices were not guided by the facility assessment. An LPN responsible for the nursing staff schedule reported scheduling staff based on census rather than resident acuity and stated not knowing what the facility assessment directed for staffing. The corporate director of finance confirmed that the LPN handled the staffing schedule. Additionally, the facility had been without a DON since mid-December, and a planned DON hire had declined the position before starting. The corporate administrator reported that the Assistant DON, an RN, had only recently returned to work and would be placed in the DON role until a new DON was hired. The facility census at the time of the survey was 26 residents.
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