Print Inspection: PXC5

Based on interview and record review, conducted during a site visit on 01/31/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:

Resident 2 no longer resided in the facility.

During an interview on 01/31/24, Staff 4 (MT) indicated the following,

·Transferring residents who require two-person assist with one staff member has happened a lot due to the lack of staff to provide those services.

·A caregiver this morning told me they had assisted a two-person transfer alone without asking for a second person today. The residents care plan stated the resident was a two-person assist.

A review of Resident 3 service plan, dated 01/24/24, indicated Resident 3 required two-person Hoyer lift assist to and from the wheelchair, shower and bed.

It was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.

On 01/31/24, the findings were reviewed with and acknowledged by Staff 1 (Executive Director).

Verbal plan of correction: The facility has revised the Agency Orientation sign off which now includes verbiage stating that the staff have read and will be held liable for completing cares per the service plans provided for our residents. Our RCC team will also have returning workers sign off that they have read and are following our residents care plans. The staff in question has been DNR'd (Do Not Return.) Lastly, the ED will complete an in-service at our next all staff on the importance of reporting incidents such as this immediately.