§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 §483.71.
§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 clinical record review, review of facility documents, and resident and staff interview, it was determined that the facility failed to have sufficient nursing staff to meet resident needs on one of two nursing units (second floor), and three of 12 residents reviewed (Resident 3, 20, and 248).
Findings include:
The facility's third floor was unoccupied by residents at the time of the onsite visit, and all facility residents were residing on the second-floor nursing unit.
Interview with Resident 20 on April 22, 2025, at 11:50 AM revealed that she needed to rely on staff to go to the bathroom, as she was not supposed to take herself, and she sometimes has "accidents" waiting for the staff. Resident 20 stated she sometimes waits up to an hour for staff to come when she rings her call bell.
Clinical record review for Resident 20 revealed a social service note dated January 13, 2025, at 11:09 AM indicating a family member of the resident expressed concern at a care plan meeting about call bell response times when the resident needs to utilize the bathroom. There was no follow up identified to the concern.
A review of Resident 20's electronic call bell activation and response records for April 10 to 24, 2025, revealed the following call bell response times greater than 20 minutes after the resident activated the call bell:
April 10, 2025, activated at 3:47 PM; response time of 22 minutes. April 10, 2025, activated at 9:15 PM; response time of 24 minutes. April 12, 2025, activated at 10:18 PM; response time of 26 minutes. April 14, 2025, activated at 10:59 AM; response time 26 minutes. April 17, 2025, activated at 6:47 AM; response time 22 minutes. April 17, 2025, activated at 4:42 PM; response time 25 minutes. April 17, 2025, activated at 7:00 PM; response time 22 minutes. April 18, 2025, activated at 5:29 AM; response time 21 minutes. April 19, 2025, activated at 8:35 PM; response time 50 minutes. April 20, 2025, activated at 3:05 PM; response time 23 minutes. April 10, 2025, activated at 4:56 PM; response time 24 minutes. April 21, 2025, activated at 12:34 AM; response time 28 minutes. April 22, 2025, activated at 3:58 PM; response time 50 minutes. April 22, 2025, activated at 6:26 PM; response time 22 minutes. April 23, 2025, activated at 3:57 PM; response time 30 minutes. April 23, 2025, activated at 8:50 PM; response time 27 minutes.
A review of Resident 20's bowel and bladder elimination records revealed staff documentation did not occur exactly at the point of service, but at some time during the shift the care occurred. Although a longer call bell response time could not be linked to the exact documentation time, it was determined that Resident 20's incontinent episodes of bowel, bladder, or both, on April 10, 14, 17, 18, and 25, 2025, had longer call bell response times.
The above information regarding Resident 20's call bell response times was reviewed with the Nursing Home Administrator on April 25, 2025, at 9:45 AM.
Clinical record review for Resident 248 revealed an admission Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated April 11, 2025, that noted facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 15, which indicated no cognitive impairment.
Clinical record review for Resident 3 revealed an admission MDS dated April 3, 2025, that noted facility staff assessed the resident as having a BIMS of 6, which indicated cognitive impairment.
An interview with Residents 3 and 248 on April 22, 2025, at 1:26 PM revealed concerns related to staff response to activated call bells. Resident 248 further stated that staff take "half an hour" to respond to the call bell and "that's a problem."
An interview with the Nursing Home Administrator and Director of Nursing on April 24, 2025, at 1:45 PM revealed that the facility documentation provided upon surveyor request for call bell response records accounted for the entire room for Residents 3 and 248.
A review of the facility documentation titled "Alerts," for Residents 3 and 248 revealed the following call bell activation dates/times with an elapsed time greater than 20 minutes:
April 9, 2025, at 10:56 AM; response time 36 minutes. April 9, 2025, at 12:56 PM; response time 34.2 minutes. April 9, 2025, at 3:50 PM; response time 32.3 minutes. April 9, 2025, at 5:29 PM; response time 25.2 minutes. April 9, 2025, at 6:00 PM; response time 43.1 minutes. April 9, 2025, at 6:57 PM; response time 39.5 minutes. April 9, 2025, at 9:50 PM; response time 27.7 minutes. April 10, 2025, at 10:50 PM; response time 31.7 minutes. April 11, 2025, at 5:12 AM; response time 34.2 minutes. April 11, 2025, at 7:25 PM; response time 23.5 minutes. April 12, 2025, at 11:02 AM; response time 40.9 minutes. April 12, 2025, at 8:00 PM; response time 26 minutes. April 12, 2025, at 8:10 PM; response time 46 minutes. April 12, 2025, at 9:56 PM; response time 23.6 minutes. April 13, 2025, at 7:10 PM; response time 44.1 minutes. April 13, 2025, at 8:35 PM; response time 24.7 minutes. April 14, 2025, at 6:13 AM; response time 22.6 minutes.
The excessive call bell response times for Residents 3 and 248 were reviewed during an interview with the Nursing Home Administrator on April 25, 2025, at 1:14 PM.
28 Pa. Code 201.18(b)(1)(3) Management
28 Pa. Code 211.12(d)(1)(3)(4)(5) Nursing services
| | Plan of Correction - To be completed: 06/09/2025
- Call Bell audit completed for Resident # 3,20,248 with follow up reporting no unmet needs. - The Director of Wellness or Designee will conduct initial quality Improvement (QI) monitoring of Call Bell response times and resident interviews to ensure resident needs are being met. - The Director of Wellness or designee will reeducate staff on call bell response time and response to resident needs. - The Director of Wellness or Designee will conduct Quality Improvement (QI) monitoring of call bell response time and response to resident needs 5x per week x2, then weekly x3, then monthly x 2. Further recommendations will be reported to Quality Assurance Performance Improvement (QAPI)
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