§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.
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Observations:
Based on review of facility policy, clinical records, facility documentation, and the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2019 (RAI-assessment guide used to plan the provision of care for residents), observations, and resident and staff interviews, it was determined that the facility failed to ensure sufficient nursing staff to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being for 10 of 21 residents reviewed (Residents R14, R20, R61, R9, R19, R29, R36, R43, R57 and R177).
Findings include:
Review of a facility policy entitled "Activities of Daily Living (ADL), Supporting" with a revision date of March 2018, and a policy review date of 4/24/24, revealed " Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care), mobility (Transfer and ambulation, including walking), elimination (toileting), Dining (Meals and snacks), and communication (speech, language, and any functional communication systems).
Review of the RAI manual instructions for Section C0500 "Brief Interview for Mental Status (BIMS)" revealed that a score of 13-15 identified a resident as cognitively intact and a score of 8-12 identified a resident as moderately impaired, and a score of 0-7 as severly impaired.
Resident R20's clinical record revealed an admission date of 9/14/21, with diagnoses of cognitive communication deficit (trouble participating in conversations), parkinsons (disorder of the central nervous system that affects movement, often including tremors), protein- calorie malnutrition (overall lack of calories and protein deficiency the body needs to function), and dementia (disease of the brain that affects mood, behavior, and decision making).
Resident R20's Minimum Data Set (MDS- a periodic assessment of care needs) Section C - Cognitive Patterns Section C0500 dated 6/20/24, revealed Resident R20 with a BIMS score of 99 due to resident is rarely/never understood and unable to complete interview. Resident R20's MDS 3.0 Section G dated 6/20/24, - Functional Status (Transfer-how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet) revealed Resident R20 as an extensive assistance with a two or more persons physical assist for transfer.
Resident R20's physician orders dated 6/04/24, revealed resident to be out of bed to broda chair (type of positioning chair) for lunch and dinner.
Observations on 6/30/24, at 11:10 a.m., 12:35 p.m. and 3:45 p.m. revealed Resident R20 laying in bed on his/her right side. Further observations on 7/01/24, at 10:00 a.m. and 12:15 p.m revealed Resident R20 laying on his/her back in bed. On 7/02/24, at 10:05 a.m, 11:20 a.m. and 12:40 p.m. revealed Resident R20 laying in bed on right side. Resident R20 was not observed out of bed for meals on 6/30/24, 7/01/24, or 7/02/24.
Resident R61's MDS Section C - Cognitive Patterns Section C0500 dated 6/20/24, revealed Resident R61 with a BIMS score of 15/15, cognitively intact. Resident R61's MDS 3.0 Section G dated 6/20/24, - Functional Status (Transfer-how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet) revealed Resident R61 as an extensive assistance with a two or more persons physical assist for transfer.
Observations on 6/30/24, at 11:05 a.m., 12:55 p.m. and 3:40 p.m., revealed Resident R61 in bed laying on his/her back with a hospital gown on. Observations on 7/02/24, at 10:00 a.m., 11:20 a.m. and 12:45 p.m. revealed Resident R61 laying in bed in same position on his/her back. An interview with Resident R61 on 7/02/24, at 12:45 p.m. indicated he/she is reluctant to get out of bed due to sometimes he/she has to sit in his/her chair for long periods of time, due to staff being too busy to get him/her back in bed. Resident R61 further indicated that he/she cannot sit in chair for long periods of time due to severe back pain but enjoys getting out of bed. Resident R61 stated, "I love to get out of bed, but just want to get back into bed when my back starts to hurt."
An interview with the Director of Nursing (DON) on 7/02/24, at 12:50 p.m. confirmed Residents R20 and R61 were in bed laying as noted above, as they were observed throughout morning and afternoon hours. The DON confirmed that Resident R20 and R61 should be turned/repositioned often and offered to get out of bed.
Resident R14's clinical record revealed an admission date of 3/27/24, with diagnoses of depression, BPH (benign prostatic hyperplasia is an enlarged prostate and cause problems with urination in a man), CKD (chronic kidney disease is a longstanding disease of the kidneys), and need for a suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow).
Resident R14's MDS Section C - Cognitive Patterns Section C0500 dated 6/20/24, revealed Resident R14 with a BIMS score of 9, moderately impaired. Resident R14's MDS 3.0 Section G - Functional Status (Transfer-how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet) revealed Resident R14 as an extensive assistance with a two or more persons physical assist for transfer.
Resident R14's physician orders dated 5/29/24, revealed Resident R14 was to be out of bed for all meals.
Observations on 7/01/24, at 10:30 a.m. revealed Resident R14 laying in bed on his back with the catheter bag (collection bag for urine) in bed near the resident's feet entangled with the bed linen. Further observations on 7/01/24, at 1:00 p.m., 2:05 p.m. and 3:00 p.m. revealed the same as noted prior. Resident was not observed out of bed for meals on 7/01/24, and 7/02/24.
An interview with Registered Nurse (RN) Employee E2 on 7/01/24, at 2:05 p.m. confirmed Resident R14 was laying in bed on his/her back with the catheter bag near his/her feet entangled with the bed linen. A further interview on 7/01/24, at 3:15 p.m. with the Regional Clinical Director confirmed Resident R14 should be repositioned often throughout day including the safe positioning of the catheter bag.
During a resident interview on 6/30/2024, at 2:12 p.m. Resident R29 voiced concerns that there are frequently long waits for call bell responses. Particularly about two nights prior, Resident R29 called to get assistance to use the restroom and waited over an hour with no assistance. "Staff try to do their best, but they need more help to assist residents and provide care." Resident R29 also stated that newer staff members are not trained properly and have to work too fast. They don't clean residents up properly. Resident R29 revealed this has been a problem in the last month since the facility was taken over by new management.
During a resident interview on 6/30/2024, at 2:22 p.m. Resident R57 voiced concerns that the facility does not have enough nursing staff. Resident R57 revealed that about two nights ago there was only one nurse aide on duty and there was a one or two hour wait to get assistance for incontinence care resulting in Resident R57 laying in urine for long periods of time. There are frequently long waits for assistance and care due to not enough staff. Resident R57 revealed that breakfast meals are frequently cold by the time they get to the residents because there are not enough staff to deliver the food trays to residents.
During a resident interview on 6/30/2024, at 2:33 p.m. Resident R177 voiced concerns that there are frequent waits for staff assistance when calling on the call bell. In particular, at nights and weekends. Resident R177 revealed that about two nights prior there was very low staffing overnight and waited two hours for assistance when calling on the call bell.
During a resident interview on 6/30/2024, at 2:40 p.m. Resident R43 voiced concerns that there is not enough staff to accommodate resident needs and frequently wait over an hour when calling for assistance depending on how many staff are working.
During a Resident Council meeting on 7/1/2024, from 10:30 a.m. through 11:30 a.m. Residents R9, R19, R29, R36, R43, and R57 voiced concerns with insufficient nursing staff, elicited complaints of extended wait times for call lights to be answered and untimely assistance with toileting/personal care and general assistance.
Review of Resident Council minutes for April, May, and June of 2024, revealed resident concerns that there are long wait times to get assistance from staff when ringing the call bells, or staff answering the bells, and turning them off then come back when they are done working with other residents due to not enough staffing.
28 Pa. Code 211.12 (d)(4) Nursing services
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(a)(3) Management
| | Plan of Correction - To be completed: 08/19/2024
A nursing assessment will be completed on each resident (R#20, R#61, R#14, R#29, R#9, R#19, R#36, R#43, R#57, and R#177) to determine that residents were not negatively affected by the deficient practice. R#20 will be turned/repositioned and out of bed for lunch and dinner meals, as indicated in physician order. R#61 will be turned/repositioned and out of bed for all meals, as indicated in physician order, and per resident request. R#14 will be turned/repositioned frequently. R#9, R#19, R#36, R#29, R#57, R#177, R#43, and family members will educated (at resident and family council) to notify nursing supervision regarding concerns with call bell wait times. All residents will receive assistance timely. The facility will ensure that services are provided by sufficient numbers of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. The Staff Development Nurse or designee will educate all nursing staff on ensuring that the facility is providing nursing care to all residents in accordance with resident care plans on a 24-hour basis, specifically turning/repositioning frequently, answering call bells timely, and following physician's orders to have residents out of bed for all meals, as indicated by the end of July. The Director of Nursing or designee will complete rounding audits to ensure that staff are providing nursing care to all residents in accordance with resident care plans on a 24-hour basis. Administrative nurses and off-shift nurse supervisors will assist with said audits. Audits will include visual observations, staff family, and resident interviews, and testing call bell response times. Audits will occur once a week for one month, biweekly for one month, then randomly thereafter for three months. Random audits will be conducted at least 5 times per month. Audits will be reviewed at the quarterly QAPI Meeting and additional recommendations will be made as indicated.
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