cms_WV: 9866
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9866 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2012-08-23 | 353 | E | 1 | 0 | XBKB11 | . Based upon record review, resident interview, confidential staff interviews, and staff interview, the facility failed to ensure adequate staffing levels across all shifts to meet the needs of dependent residents such as assisting the residents to the bathroom and answering call lights in a timely manner. This had the potential to affect all residents who were dependent or required staff assistance. Facility census: 65. Findings include: a) Review of the facility complaint files on 8/20/12 at 2:50 p.m. found a documented complaint dated 04/12/12. The daughter of Resident #23 came to the nursing station at 7:45 p.m. She had found her mother sitting in the dark in her room in her wheelchair soaked in urine. Facility documentation was made on an incident report. Under the sections "Contributing Factors" and "Prevention" was recorded "Resident should have been put to bed once the CNA put resident in the room. (Local church group was wanting staff to take residents to church on NCFII (one of two separated units in the facility). It was also shift change. Having staffing problems." b) Review of facility resident council meeting minutes, on 8/20/12 at 2:00 p.m., found that during the meeting of 06/28/12, four (4) residents had expressed concerns about staff response to call lights. The minutes (typed as written) stated: "Call Lights and Call Response Time 20 minute wait and Bells being turned off." This concern was then found included on a complaint form which was also dated 6/28/12. Under the "Report of complaint investigation" section, the former director of social services had documented (typed as written): General consensus that the call bells were not always answered promptly However no specific dates or times given Call light/bell study - all shifts in various rooms to determine length of response and develop system for faster results/response times. The section "Was complaint valid?" was checked "yes". The results of the Call light/bell study were requested from the administrator, Employee #64 on 8/22/12 at 3:00 p.m. On 8/23/12 at 8:08 a.m., the administrator stated that no audit had been completed and no response was ever made to the residents. c) Two (2) nursing assistants were interviewed. Both expressed that they would only speak with the promise of confidentiality. Nursing assistant "a" stated that nursing assistants are being required to document care as completed when in fact it cannot all be done because there is not sufficient staff. Nursing assistant "b" stated that there was not sufficient staff to provide needed care and that "someone could fall and we wouldn't even know it." d) The director of nursing, Employee #2, was interviewed on 08/21/12. She stated there was not sufficient staff to permit someone to stay with every resident who needed supervision for safety. This comment was made during an interview about Resident #28, who had been left unattended in the bathroom, fallen, and sustained a fracture on 07/24/12. The resident had been assessed as requiring staff to be in attendance when on the toilet. e) The facility consists of two (2) units separated by two floors and it is not logistically possible for nursing assistants working on one unit to respond to lend assistance on the other when it is needed. Forty-six (46) of the facility's seventy-six (76) beds are on one unit, while the thirty (30) remaining beds are on another. It requires walking through an underground tunnel, and the taking an elevator or walking up two (2) flights of stairs to go from nursing care unit one to nursing care unit two. Review of the resident census and condition of residents (CMS-672) information, provided by the facility on 08/20/12, found that of the current census of 65, only 2 were independent for bathing, 8 were independent for dressing, 21 were independent for transferring, and 13 were independent for toilet use. Forty-two (42) were listed as independent for eating. All of the other residents either required the assistance of one or two staff for those tasks, or were completely dependent upon staff to provide that care. Information was requested from Employee #2 on 08/22/12 regarding residents that usually or always required 2 nursing assistants to provide or assist with bathing, dressing, transferring, toilet use, or eating. It was found that 12 of the residents on Unit one always required the assistance of 2 staff to provide care, and 4 often required the assistance of 2 staff to provide care. It was found that 8 of the residents on Unit 2 always require the assistance of 2 staff, and 1 often required the assistance of 2 staff. f) The following residents were identified by the facility a interviewable. They were asked if the facility had enough staff to provide care in a timely manner to all the residents. Resident #1 was interviewed on 8/22/12 at 2:20 p.m. She stated there is not enough help. Sometimes she had to wait a long time for help, and sometimes it came too late. She said that "All the girls are always stressed out here because they can't keep up with it." Resident #26 was interviewed on 08/22/12 at 3:20 p.m. She stated "No, there is absolutely not enough. If they are busy with someone else, you can wait a half hour or even an hour for toileting, getting in and out of bed, and so forth. They are all very nice to us, and do their best, but they can't keep up with it. Anybody you ask will tell you that except for the big bosses." Resident #62 was interviewed on 08/22/12 at 3:45 p.m. She said "Definitely not enough staff. Sometimes you have to wait an awful long time, especially if you're on the toilet. I have sat in that toilet seat for almost an hour. I think something should be done about it." Resident #49 was interviewed on 08/22/12 at 4:00 p.m. He stated "They are burning the candle at both ends. They get worn out. They do their best, but there is no way they can keep up with it all." Resident #22 was interviewed on 08/22/12 at 4:12 p.m. He replied "There is not enough at all. They do the best they can, but they cannot keep up. Lots of people need two staff to help them and so there's no one available when you need them. It is not unusual to wait one half to an hour when you ring the call bell. That light could be something minor like wanting some crackers like I'm eating here, or you could be choking to death and unable to tell them what you want. It is a big problem here." . | 2015-08-01 |