§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.
§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.
§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.
§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.
§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.
§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
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Observations:
Based on review of minutes from the Residents' Council meeting and resident and staff interviews it was determined that the facility failed to provide care in a manner and environment, which promotes each resident's quality of life, by failing to respond timely to residents' request for assistance as evidenced by experiences reported by five residents out of five sampled (Residents 14, 11, 9, 13 and 10 ).
Findings include:
During interviews conducted throughout the day tour of duty on March 6, 2024, the residents stated that they feel the facility is not adequately staffed because they wait extended periods of time for staff to respond to their requests for assistance, including untimely responses to their requests via the nurse call bell system.
A review of minutes from the Residents' Council meeting on February 1, 2024, revealed that Resident 14 was requesting staff assignments be reassessed as he has been left in the bathroom for long periods of time when his assigned aide is off the floor. He reported that staff tell him they do not have him on their assignment and do not provide the necessary assistance, which has caused him to wait extended periods of time in the bathroom.
Interview with Resident 11 on March 6, 2024, at 10:43 AM revealed that she feels that short staffing and agency nursing staff are a problem in the facility. She stated that over that last couple of days "I would ring the bell to use the bathroom because I can't do it myself. I had to wait over an hour. I couldn't hold it and, unfortunately, I soiled myself."
Interview with Resident 9 on March 6, 2024, at 11:15 AM, revealed that she has waited over 2 hours for staff to answer her call bell. The resident stated that these long waits often occur an hour or so around shift changes. Resident 9 reported that on March 4, 2024, she was put in bed at 7:30 PM. At 1:00 AM an aide came in to check if the resident needed to be changed, and the resident replied that she did not at that time. Resident 9 stated she woke at 5:00 AM and activated the call bell as she needed to use the bathroom at that time. No one answered her call bell until 6:20 AM, when an aide "peeked in" the resident's room and said she would tell the other girls that she needed to be changed. Resident 9 stated that she soiled herself waiting for staff assistance. It was not until 7:30 AM, 2.5 hours after Resident 9 activated her call bell for assistance, that a nurse aide came in the resident's room to provide assistance. Resident 9 stated that she was so saturated with urine by that time that they had to change all the bed linens. She stated, "I was so embarrassed, but I couldn't help it, I had to go."
Interview with Resident 13 on March 6, 2024, at 11:30, revealed that the resident stated he has learned to do everything for himself because staff "take forever to answer the call bell" and provide assistance when needed.
Interview with Resident 10 on March 6, 2024, at 12:00 PM, revealed that he has waited over an hour for staff to answer his call bell. The resident stated that these waits occur mostly on 2nd shift (evening shift). He further stated he feels that short staffing is a problem in the facility that creates these long waits for residents to receive personal care and assistance when requested from nursing staff.
Interview on March 6, 2024, at approximately 2:15 PM with the Director of Nursing (DON) verified that it is her expectation that all residents be treated with dignity and respect. The DON was unable to explain why multiple residents are reporting untimely staff response times to their call bells and requests for assistance, resulting in the residents' feelings that the facility is not adequately staffed, which was negatively affecting the residents' quality of life in the facility.
28 Pa. Code 201.18 (e)(1) Management
28 Pa. Code 201.29 (a) Resident Rights
28 Pa. Code 211.12 (c)(d)(4)(5) Nursing Services
| | Plan of Correction - To be completed: 04/02/2024
Step 1: Unable to retroactively address for residents 14, 9,11, and 10.
Residents 13 is Independent for all ADL's.
Step 2: Interview will be completed with residents with BIMS greater than 12 concerning call light wait times. (Social Service of designee)
Step 3: Education to staff in each department on responding to call lights promptly and meeting needs of resident or getting someone who can address resident's needs. Licensed nurse to check random call lights to assure resident needs met timely. (Clinical Educator or designee)
Step 4: Random interviews of resident with BIMS greater than 12 and call bell response audits randomly throughout the day weekly X4 Monthly X2 with results to QAPI monthly for three months.
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