|§483.35(a) Sufficient Staff. |
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).
§483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (e) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.
§483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
Based on observations, clinical record and incident investigation review and resident interviews it was determined that the facility failed to provide and/or efficiently deploy sufficient nursing staff to consistently provide timely quality of care, services and supervision to maintain the physical and mental well-being of the residents in the facility.
Observations conducted during the day of the survey of April 16, 2019, revealed that Resident 8 was seated in the hallway in front of his room, positioned next to the handrails. He was seated in a reclined Broda chair with a cushion to the seat. The resident was observed to continually slide down in the chair or bend at the waist as if to stand up, while verbalizing he was sliding/falling. Various staff members were observed to reposition or redirect the resident to sit down throughout the day, with the resident displaying this behavior repeatedly.
During observations st 12:30 p.m., on April 16, 2019, the surveyor observed the resident lying on his back on the floor, in front of the Broda chair in the hallway. Staff members remarked to the nurse assessing the resident, that he had been displaying these behaviors for "awhile."
Observation of Resident 8 at 4:20 p.m. on April 16, 2019, revealed that he was seated by the nurses station in the Broda chair next to the wall/handrails. The Broda chair was reclined and a heavy straight back chair with arm rests was observed placed in the opposite direction of the chair. The resident's legs were observed to be partially on the reclined portion of the chair and the bottom of his legs and feet on the straight back chair. This position impeded the resident's ability to get up and out as the positioning of the two chairs were preventing his freedom of movement.
A review of the resident's clinical record revealed no indication that this seating arrangement, which physically restrained the resident, had been assessed for its safety, appropriateness and necessity in treating the resident's medical symptoms and had not been implemented solely for staff convenience to most readily control the resident's behaviors with the least amount of staff effort.
Observations on the D hall at 12:05 p.m. on April 16, 2019, revealed that a blister pack of Amiodarone 400 mg (antiarrythmia drug) was on top of the medication a hemostats (surgical clamp). These potentially hazardous items were accessible to residents observed wandering in the area. There was no staff supervision in the area and wandering residents were observed in the area.
Observations conducted at 3:15 p.m. on April 16, 2019, revealed that a male resident was ambulating Resident 15, hand in hand out of room 5, located to the side of the nurses station.) This resident stated that residents frequently ambulate in and out of his and other resident rooms, but Resident 15 "was not a problem like some of the other residents who wander."
A review of Resident 4's clinical record revealed she had diagnoses of dementia without behavioral symptoms, adjustment disorder with mixed anxiety and depression, compounded with her inability to communicate in English.
Review of the resident's clincal record revealed that the resident had a long history of wandering in common areas of the facility and in and out of resident rooms. As a result of this wandering, the resident was involved in various altercations with peers. A review of these altercations revealed that some led to physical abuse of the resident (October 18, 2018, January 11, 2019, Januray 12, 2019, March 18, 2019 and April 3, 2019).
According to a review of a facility investigation into an incident and Resident 4's clinical record, on March 18, 2019 at 9:23 p.m., the resident was found on her back after she had wandered into another resident's room (Room D-15.) Blood was noted to the back of the Resident 4's head. The resident was sent to the emergency department and returned with two staples to the back of her head.
Resident 11, who resides on the same unit as Resident 5, was interviewed at 2:00 p.m. on April 16, 2019. According to review of this resident's most recent MDS Assessment dated 2/9/19 his BIMS was 15. Resident 11 stated that he did not mind Resident 4 coming into his room because "she was harmless and did not know any better." The resident stated, however, that there was currently not enough staff to adequately supervise residents or provide timely care to residents. Resident 11 stated that the man across the hall (identified as Resident 5) becomes very angry and threatening, using foul language, when residents wander near or into his room.
A review of Resident 5's clinical record confirmed the account reported by Resident 11. According to review of Resident 5's clinical record he was verbally abusive to residents singing outside the room on March 17, 20, 21, 24, 25, 26, and April 9, 2019.
A review of a facility investigation into an incident and a corresponding Pennsylvania Bulletin 22 (Report form for investigation of alleged abuse, neglect and misappropriation of property,) initiated by the facility on April 3, 2019, revealed that Resident 4 wandered into Resident 5's room again. Staff members heard Resident 5 yelling. As staff entered Resident 5's room, they witnessed Resident 5 push Resident 4. Resident 4 was observed falling to her buttocks and hitting her head on the side of the bathroom door. The resident sustained a 1 cm laceration to her head.
According to documentation, on April 6, 2019, the staff responded when resident 5 was "yelling profanities in his room using vulgar expletives, saying,"I will kill every one of you "c**ts!", and "you think that I harmed that little Russian lady?! (Resident 4) You haven't seen nothing, yet!"
Staff were aware of Resident 4's history of wandering and incidents of resident to resident physical abuse as well as Resident 5's intolerance and threats to his peers, but the facility did not sufficiently supervise these residents to prevent these resident to resident altercations and subsequent resident injuries.
Observations conducted at 3:05 p.m. on April 16, 2019, revealed that Resident 4 wandered into Resident 13's room. Resident 13 verbally asked Resident 4 (who does not speak English) to leave and when she did not, Resident 13 took her hands to lead Resident 4 out of her room. Resident 4 began resisting and pulling her hands away. Resident 13 began raising her voice for her to leave. The surveyor requested staff assistance as staff at the nurses station, two doors down from the resident's room, were unaware of the incident.
Resident 12 was observed wandering about her unit hallways throughout the day of the survey and into the resident room across the hallway from her's at 3:25 p.m. on April 16, 2019. A staff member walking by the resident's room, was observed to notice the resident and direct her out of the other resident's room.
When interviewed at 2:40 p.m., Resident 6, whose most recent MDS Assessment was conducted on 2/14/19, revealed that Resident 6's cognition was intact (BIMS 15). The resident stated that the facility was not adequately staffed to provide necessary and timely care. The resident stated that the facility had recently hired more nursing assistants, but the 7 AM to 3 PM shift was still unable to provide needed assistance to residents and care in a timely manner.
28 Pa. Code 211.12(a) Nursing services
Previously cited. 2/9/19,11/19/18,10/16/18,7/9/18,4/17/18
28 Pa. Code 211.12(c) Nursing services
Previously cited. 2/9/19,11/19/19,7/9/18,4/17/18
28 Pa. Code 211.12(d)(1) Nursing services
Previously cited. 2/9/19,11/19/18,7/9/18,4/17/18.
28 Pa. Code 211.12(d)(5) Nursing services
Previously cited. 2/9/19,11/19/18,7/9/18,4/17/18.
28 Pa. Code 201.18(e)(1) Management
Previously cited: 2/9/19, 11/19/18, 7/9/18.
28 Pa. Code 201.18(e)(3)(6) Management
| ||Plan of Correction - To be completed: 05/28/2019|
1. The facility will maintain sufficient nursing staff to provide timely quality of care, services and supervision to maintain the physical and mental well being of our residents.
2. Staffing patterns have been reviewed and deployed as needed to meet the needs of the residents
3. The nursing management staff will be educated on Focus on F-tag 725 Sufficient Nursing staff and staffing patterns. Staffing patterns will be reviewed daily and staff adjusted based upon the needs of the units
4. A weekly staffing summary will be presented to QA for review and modification based upon the changing needs of the residents