§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.
|
Observations:
Based on a review of facility policy, resident observations and interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 13 of 16 residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, and R13).
Findings include:
Review of the facility policy, "Nursing Department Staffing" dated 11/30/23, indicated "The facility will 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:
-Licensed nurses
-Other nursing personnel
During an observation on 2/25/24, at 1:15 p.m., Resident R1 was noted to have long, greasy-appearing hair, that was not brushed.
During an observation on 2/25/24, at 1:16 p.m., Resident R2 was noted to be wheeling around the dining room, with bare feet.
During an observation on 2/25/24, at 1:22 p.m., Resident R3's room smelled of urine. Upon entering the room, the surveyor stepped in a yellow liquid on the floor. The sheet was noted to have a large, yellowed, circular area on the middle of it, dry to the touch.
During an interview on 2/25/24, at 1:25 p.m., when asked about facility staffing and care, Resident R4 stated, "I've had so many bad experiences with that." "They don't empty the urinal, say they have to get gloves, and they don't come back." "They don't help me wash up." When asked about call light response, Resident R4 stated, "Forever."
During an observation on 2/25/24, at 2:27 p.m., Resident R5 was noted to have a soiled shirt on, one sock on, one foot bare, long jagged fingernails, toenails that were jagged and appeared to have a red substance on them.
During an interview on 2/25/24, at 2:30 p.m., when asked about facility staffing and care, Resident R6 stated, "There are not enough people." When asked about call light response, Resident R6 stated, "Call lights are long sometimes."
During an interview on 2/25/24, at 2:32 p.m., when asked about facility staffing and care, Resident R7 stated, "No, they work too hard."
During an observation on 2/25/24, at 2:35 p.m., Resident R8 was noted to food spilled on his shirt and greasy appearing hair.
During an interview on 2/25/24, at 2:38 p.m., when asked about facility staffing and care, Resident R9 stated, "There's never enough." When asked about call light response, Resident R9 stated, "They are too busy."
During an observation on 2/25/24, at 2:45 p.m., Resident R10 was noted to have unbrushed, greasy appearing hair.
During an interview on 2/25/24, at 2:49 p.m., when asked about facility staffing and care, Resident R11 stated, "There's not enough aides on the weekend." When asked about call light response, Resident R11 stated, "Yesterday our button wasn't working. I was waiting from 9:20 until 10:30-11:00."
During an interview on 2/25/24, at 2:55 p.m., when asked if there was sufficient facility staffing and care, Resident R12 stated, "No!" When asked if staffing was worse on the weekends, Resident R12 stated, "Oh yeah."
During an interview on 2/26/24, at 11:00 a.m., when asked if there was sufficient facility staffing and care, Resident R13 stated, "Absolutely not. Some aides never answer the call light. I've waited for over an hour."
Confidential staff interviews conducted during the survey about sufficient facility staffing indicated the following:
Employee E1 stated "It's terrible."
Employee E2 stated, "Almost all the staff are agency, and they never show up."
Employee E3 stated, "I'm agency, so it's fine with me."
Employee E4 stated, "I have to do my job, and other peoples' jobs too because they don't have enough."
During an interview on 2/26/24, at approximately 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to have sufficient nursing staff to provide nursing and related services to 13 of 16 residents.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(e)(6) Management.
28 Pa. Code: 201.20(a) Staff development.
28 Pa. Code: 211.12(a) (c)(d)(1)(2)(3)(4)(5) Nursing services.
| | Plan of Correction - To be completed: 04/02/2024
The facility will have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of its residents. Resident R1's hair was washed and brushed. Footwear was placed on resident R2's feet and careplan was updated to ensure appropriate footwear is on at all times. Resident R3's room floor was mopped and bed sheets changed. Resident R5 was washed and put in a new pair of clothes – fingernails and toenails also appropriately trimmed. Resident R8 was washed and changed and hair was brushed. Resident R11's call-bell checked to ensure it is fully functioning.
The Nursing Home Administrator with re-educate the Director or Nursing and HR/Scheduler on federal tag F0725 and the requirement to employ sufficient staff to carry out nursing services to maintain the highest practical physical, mental, and psychosocial well-being of residents.
The administrator or designee will audit staffing levels to ensure sufficient nurse staffing is provided to carry out nursing services that maintain the highest practical physical, mental, and psychosocial well-being of residents. The Director of Nursing or designee will complete call-bell audits 5x/ week x4 weeks and then monthly x3 months to ensure appropriate call bell response. Director or Nursing or designee will also audit 5 shower/bed bath task records, resident fingernails, and clothing to ensure it is clean and appropriate weekly x4 weeks and then monthly 3 months to ensure appropriate hygienic care is being given as ordered.
The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.
|
|
