Inaccurate Facility Assessment of Respiratory Care Capacity and Staffing
Penalty
Summary
The deficiency involves the facility’s failure to complete an accurate facility-wide assessment of the resources needed to care for residents, including during day-to-day operations and emergencies. The written facility assessment stated that the facility treats a wide range of patients transitioning from hospital to home and that, prior to admission, the DON and interdisciplinary team assess residents’ physical and psychosocial needs to determine appropriate placement. The assessment also indicated that special treatments available in the facility included respiratory services such as oxygen therapy, suctioning, tracheostomy care, and ventilator or respirator care, and it listed specific numbers for these services (oxygen therapy 15, suctioning 5, tracheostomy care 0, ventilator/respirator care 2). However, the assessment did not include information on staffing needs for residents receiving respiratory services. During an interview, an RT reported that there were two residents with a tracheostomy and two residents with ventilators in the facility, which did not match the facility assessment’s indication of zero tracheostomy care and capacity for only two ventilator/respirator residents. In a separate interview, the Administrator stated that, in the facility assessment, they had entered the average number of residents usually present with certain care needs rather than the number of residents the facility was able to care for based on those needs. The Administrator further stated that the facility was able to admit ten residents with ventilators, confirming that the assessment was not based on the services the facility could provide and that there was no specific number or types of staffing requirements listed to address the needs of residents on ventilators or receiving tracheostomy services. This inaccuracy had the potential to affect all 49 residents in the facility.
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