§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 observations, a review of clinical records, grievances lodged with the facility and nurse staffing levels and staff interviews it was determined that the facility failed to provide and/or efficiently deploy sufficient nursing staff to consistently provide timely care, including assistance with activities of daily living, to meet the physical needs and promote the psychosocial well-being of each resident including Resident 4, Resident 2, Resident CR1 and CR2).
Findings include:
A review of a grievance submitted by Resident 4's representative dated January 23, 2024, revealed that the resident's representative had "to physically call facility herself and ask for someone to answer her mother's call bell since no staff had answered the call bell."
Review of the facility's resolution revealed that on January 24, 2024, nursing staff were provided written and/or verbal education via telephone to "please be attentive to answering call bells. A resident call bell should be answered within 5-10 minutes. It is everyone's job to answer call bells, not just CNAs (nurse aides). Please do not walk by a call bell without addressing the resident's needs." Education was also provided regarding resident showers, which noted that "all residents get two showers a week and bed baths in between. If a resident wants a shower more often, then it should be provided. COVID positive residents still need showers. They should shower last after the negative residents are already showered. Shower room should be cleaned by housekeeping after all COVID positive showers are done."
Observation of the first-floor nursing unit on February 21, 2024, at approximately 6:20 AM, 42 residents were residing on the unit. There was one LPN and 2 nurse aides assigned to the unit. At time of observation, the registered nurse supervisor was seated at the nurse's station taking care of medications for a resident no longer in the facility.
Observation on the second-floor nursing unit on February 21, 2024, at approximately 6:30 AM, 44 residents were residing on the unit. There was one LPN (license practical nurse) on the unit and 2 nurse aides assigned to care for the residents. Upon arrival to the second-floor resident unit at 6:30 AM, there were 4 resident room call bells sounding on one side of the hall. At that time, Employee 1, LPN, was completing data entry while watching Resident 8, one nurse aide, Employee 2, was tending to residents on the other side of the hall, and the other nurse aide, Employee 3, was completing data entry for her shift. No one was observed responding to sounding call bells. Continued observation revealed that it took 20 minutes for the second-floor nursing staff to respond to the 4 call bells.
Review of staff assignment sheet revealed that Employee 3 had been assigned to the area of the unit on which the 4 residents' call lights were sounding but continued to do data entry instead of responding to residents requests for assistance.
Continued observation revealed that at 6:55 AM, approximately 20 minutes later, Employee 2 responded to the residents' call bells.
Interview with the Nursing Home Administrator on February 21, 2024, at approximately 2:30 p.m. revealed the expectation was for staff to answer call bells within 5-10 minutes and provide the requested assistance to residents.
Interview with Employee 1, LPN, on February 21, 2024, at 7 AM revealed that Resident 8 had been admitted on February 20, 2024, and due to behaviors, required 1:1 observation during the 11 PM to 7 AM shift. According to Employee 1, the night shift nursing supervisor assisted with sitting with resident during the night, but was not able to continue to watch the resident throughout the entire shift. This required each assigned staff member on the second floor to alternate watching Resident 8 while attempting to meet the care needs of the other 43 residents on the unit.
Observation of shift change from night shift to day shift on February 21, 2024, revealed that there was no staffing sheet available for the oncoming shift, which resulted in the on-coming staff be unaware of which unit to report for duty. The oncoming staff were unable to timely to timely report to the unit to which they were assigned due to the lack of a deployment sheet upon start of the shift.
Review of Resident 2's clinical record revealed admission to the facility on February 2, 2024, with diagnoses, which included hypertension, chronic kidney disease, and hyperlipidemia (high cholesterol).
A review of Resident 2's admission MDS Assessment (Minimum Data Set-a federally mandated standardized assessment process completed periodically to plan resident care) dated February 9, 2024, revealed that the resident was cognitively intact, that it was very important to choose between a tub bath, shower, bed bath, and required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) from staff for showers/ bathing.
Review of Resident 2's Documentation Survey Report dated February 2024 revealed that the facility did not identify the resident's scheduled shower or bath days on the nurse aide's assignment. Further review of the report revealed that there was no evidence that Resident 2 was provided a shower since admission. According to the report, the facility's nursing staff provided Resident 2 only bed baths from admission on February 2, 2024, through February 20, 2024, when reviewed during the survey on February 21, 2024.
Review of Resident CR1's clinical record revealed admission to the facility on February 6, 2024, with diagnoses which included congestive heart failure, heart disease, and chronic obstructive pulmonary disease. Resident CR1 was discharged from the facility on February 12, 2024.
A review of Resident CR1's admission MDS Assessment dated February 6, 2024, revealed that the resident was cognitively intact, that it was very important to choose between a tub bath, shower, bed bath, and required partial/moderate assistance (helper does less than half the effort. Helper lifts or holds trunk or limbs but provides less than half the effort) from staff for showers/ bathing.
Review of Resident CR1's Documentation Survey Report dated February 2024 revealed that the resident received a bed bath on February 6, 2024. There was no documented evidence that nursing staff provided or offered the resident a shower during her stay at the facility. Further review of the clinical record failed to provide evidence that the resident was provided the opportunity to choose the time of day she would prefer to be showered.
Review of Resident CR2's clinical record revealed admission to the facility on January 25, 2024, with diagnoses which included COVID-19, depression, and stroke. Resident CR2 was discharged from the facility to home on February 12, 2024.
Review of Resident CR2's admission MDS Assessment dated February 1, 2024, revealed that the resident was cognitively intact, that it was very important to choose between a tub bath, shower, bed bath, and required partial/moderate assistance from staff for showers/ bathing.
Review of Resident CR2's Documentation Survey Report dated February 2024 revealed that the facility did not schedule a shower/bath day for the resident and none was assigned to the nursing the staff. There was no evidence that nursing staff showered Resident CR2 during the resident's stay. Nursing provided Resident CR2 only bed baths from February 1, 2024, through February 12, 2024, when the resident was discharged home.
During an interview February 21, 2024, at approximately 2 PM the Regional Clinical Nurse Consultant confirmed that residents are to receive two showers per week and confirmed that the facility was unable to demonstrate that the above residents had been showered at least twice a week.
A review of nurse staffing and resident census and staff interview, it was determined that the facility failed to consistently provide minimum general nursing care hours to each resident daily as required by PA state licensure regulations.
A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide the state minimum nurse staffing of 2.87 hours of general nursing care to each resident:
A review of the facility's calculated total nursing care hours per resident day for February 18, 2024, was at 227.50 total hours for a maximum resident census of 84 and the facility required 241.08 total hours for a maximum resident census of 84. Further review of PPD for February 18, 2024, revealed that the facility provided only 2.71 hours of direct nursing care to each resident and failed to provide the minimum of 2.87 hours of direct nursing care daily to each resident daily.
An interview with the Nursing Home Administrator (NHA) on February 21, 2024, at 2:35 PM, confirmed that the facility failed to provide the minimum of 2.87 hours of direct nursing care daily for each resident.
Refer F550, F677
28 Pa. Code 201.18 (b)(1)(2)(3) Management
28 Pa. Code 211.10 (c)(d) Resident care policies
28 Pa. Code 211.12 (d)(1)(3)(4)(5)(i)(1) Nursing services
| | Plan of Correction - To be completed: 04/02/2024
Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.
1. Resident 2's care plan was updated to reflect shower preference
Residents 4 was interviewed to reveal acceptable call bell response time
Unable to correct for residents CR1 and CR2 due to discharge from facility
2. To identify other residents that have the potential to be affected, the DON/designee reviewed non interviewable (Bims <12) shower documentation for last week to ensure they receive a shower per policy and/or preference
To identify other residents that have the potential to be affected, the DON/designee reviewed non interviewable (Bims <12) shower documentation for last week to ensure they received their shower per policy.
To identify other residents that have the potential to be affected the SW/designee will review concern forms going back 14 days to ensure residents and or families that have concerns with call bells are addressed and resolved to satisfaction.
3. To prevent this from reoccurring, the DON/designee educated nursing staff on the shower policy. If a resident refuses a shower or a shower is unable to be given a licensed nurse must be notified. Accommodations will be made to ensure residents receive their showers per their shower schedule.
To prevent this from happening again the NHA/designee will educate current staff on the call bell policy. Call ball pledges will be signed to ensure all staff answer call bells to meet the needs of the residents.
To prevent this from reoccurring, the RVPO/designee will educate the NHA and DON on reviewing the daily schedule to ensure adequate nursing staff to consistently provide timely care, including assistance with activities of daily living, to meet the physical needs and promote the psychosocial well-being of each resident
4. To monitor and maintain ongoing compliance, the DON/designee interviewed 3 residents weekly x4 then monthly x 2 to ensure they received a shower per policy and/or preference
To monitor and maintain ongoing compliance, the DON/designee reviewed shower documentation of non interviewable residents weekly x 4 then monthly x2 to ensure showers were given per policy.
To monitor and maintain ongoing compliance, the NHA/designee will review the nursing schedule to ensure adequate nursing staff to consistently provide timely care, including assistance with activities of daily living, to meet the physical needs and promote the psychosocial well-being of each resident.
To monitor and maintain ongoing compliance the NHA/DON/SW/RNAC/designee will complete 5 call bell audits weekly x 4 then monthly x 2 to encompass all three shifts to ensure call bells are being answered timely. 5 residents will be interviewed 5 days a week x 4 weeks then monthly x 2 to ensure call bells and needs are met timely.
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