Failure to Conduct Comprehensive Facility-Wide Assessment of Staffing Needs
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a comprehensive facility-wide assessment that determined the resources necessary to care for residents competently during day-to-day operations, including nights and weekends, and during emergencies. The facility’s written policy stated that a facility assessment would be conducted at least annually and as needed to determine and update the facility’s capacity to meet resident needs during routine operations and emergencies. The Facility Assessment provided during the onsite survey identified a resident population that included individuals with behavioral health needs, substance use disorders, IV medications, dialysis, oxygen therapy, and assistance needs with activities of daily living, and it documented facility resources for emergencies. However, the assessment did not determine the staffing resources necessary to meet these care needs, did not identify staffing levels needed during emergencies, and did not address what was considered sufficient staffing, particularly on weekends. The staffing breakdown attached to the Facility Assessment showed that for all three resident units (1 West, 2 West, and 2 East), with approximately 40 residents per unit and a total census of about 120 residents, there were zero RNs listed on day, evening, and night shifts. The breakdown listed only LPNs and CNAs for each shift and did not identify minimum staffing requirements specific to weekends or the number of staff needed to provide behavioral health care and services. During interviews, the staffing coordinator stated that weekends are generally less staffed, that staff call out, and that aides are moved between units to balance staffing, and also reported that staffing concerns had been discussed with nursing administration. When questioned about the absence of RN staffing and the lack of weekend and behavioral health staffing detail in the Facility Assessment, the Administrator stated that supervisors are RNs and acknowledged that the minimum staffing levels in the assessment were not separated by weekday or weekend shifts and did not identify staffing specific to behavioral health care and service needs.
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