cms_WV: 9885
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9885 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2012-05-10 | 353 | D | 1 | 0 | 1WUS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations, review of resident council meeting minutes, record review, resident interview, family interview, and staff interview, the facility failed to maintain adequate staffing levels across all shifts to ensure residents' needs were met by answering call lights in a timely manner and failed to provide needed assistance to dependent residents with eating and other needs. These practices affected more than a limited number of residents. Resident identifiers: #81, #7, #85, #61, #29, #58, #79, and #35. Facility census: 92. Findings include: a) Resident council meeting minutes Review of resident council meeting minutes, on 05/07/12 at 1:00 p.m., found that during the meeting of 04/17/12, it was noted that call lights were not being answered on the 3:00 - 11:00 shift. A review of the facility complaint file, on 05/07/12 at 1:30 p.m. found two (2) complaints regarding call lights. 1) There was a complaint from Resident #81 on 03/07/12, which stated (typed as written): "call bell not being answer. He said it take them 1 hour. Sometimes." 2) There was a complaint from Resident #7, on 04/17/12, which stated (typed as written): "Call lights not being answered in a timely manner on 3 - 11 shift." Under the section of the complaint form "What other action was taken to resolve the concern (be specific)", was recorded "Call light audit is to be completed by staff." On 05/08/12 at 2:30 p.m., an interview was conducted with the director of nursing (DON), Employee #68 regarding the issues voiced and the follow up indicated on the form. She stated there was an issue with call lights. In response to this issue, audits on different shifts and at different times were being conducted by different staff members. A review of these audits revealed an identified issue with call lights on 05/01/12 at 5:58 a.m. The audit found that the call light in room [ROOM NUMBER] was lit at 5:58 a.m., and was not answered until 6:16 a.m., a response time of eighteen (18) minutes. It was also noted that two licensed practical nurses and two nursing assistants were observed walking past the room without responding to the call light. The daughter and medical power of attorney (MPOA) of Resident #47, was interviewed in the facility on 05/07/12 at 3:20 p.m. She felt staffing and call lights were a big problem, especially on the Hilltop wing of the facility. b) Resident #81 This resident was determined to possess the capacity to make informed medical decisions by a physician on 01/08/11. His brief interview for mental status (BIMS) score, as assessed on 03/16/12, was "15", indicating he was cognitively intact. He resided on the Hilltop wing. He was interviewed on 05/07/12 at 3:00 p.m. He stated call lights are never answered in a timely manner. He said this was true on all shifts, but especially on the 3:00 - 11:00 shift. He said it was not uncommon for it to take a half hour to an hour for lights to be answered. He related that recently, on a Sunday evening, his father was visiting him. He put his light on and it was one hour and forty five minutes before staff responded. c) Resident #85 This resident's brief interview for mental status (BIMS) score, as assessed on 01/10/12 was "15", indicating she was cognitively intact. She resided on the Hilltop wing. She was interviewed on 05/08/12 at 9:30 a.m. When asked about call lights being answered timely, she stated "they just walk by." She denied telling any of the staff about the call lights not being answered, but said her mother has reported this to staff multiple times. d) Residents #61, #29, and #58 The facility was visited on the evening of 05/08/12 at 7:30 p.m. 1) At 7:32 p.m., observation of the Hilltop back hall from the nurses' station found call lights already on in room [ROOM NUMBER] and 163. At 7:45 p.m., Resident #61, in room [ROOM NUMBER], was observed. She stated she needed help. At that same time, Resident #29 in room [ROOM NUMBER] was calling out. The call lights had not been answered at this time. At 7:52 p.m., nursing assistant (NA), Employee #30, went into room [ROOM NUMBER] and the call light was turned off. This same NA (Employee #30), then went into room [ROOM NUMBER] and the call light was turned off. The NA returned to room [ROOM NUMBER] and was observed providing care to Resident #58 (this was Resident #29's roommate). After completion of care for Resident #58, the NA provided care to Resident #29. It was at least 20 minutes from the time the call lights were first observed being on, until a staff member responded. All three (3) of these residents needed help at the same time. The NA provided care to all three as best she could, but she could not care for them all at the same time. There were no other aides around at the time. 2) At 8:00 p.m., as Employee #30 was preparing to provide care for Resident #61, a brief interview was conducted. Employee #30 confirmed she had answered the lights in both rooms (166 and 163), found Resident #58 was soiled and was in the greatest need of help. She stated she did answer the light in room [ROOM NUMBER] and turned the call light off and told Resident #61 she had to provide care for another resident and would be back. When asked if there was enough help to provide care to the residents, she stated: "No, and I have told them (administration) about this before." She stated they had 4 NAs for Hilltop unit's front and back halls and that there was too much care for that number of staff. Employee #30 was asked how many residents in her assignment required an electronic lift and she stated one or two. She stated most of the lifts were on Hilltop Front hall. She was assigned 15 residents for this shift. She stated her remarks did not have to be confidential. She then proceeded to provide care for the resident in room [ROOM NUMBER]. 3) At 8:05 p.m., an interview was conducted with another NA, who requested confidentiality. She stated "there is not enough staff to provide care for the residents on Hilltop. We need more team work." When asked if the RN/LPN staff assisted in answering call lights and assisting with care, she said "No. " The call light in room [ROOM NUMBER] was lit from at least 7:32 p.m. until 7:52 p.m., or twenty minutes. The light was turned off with the promise to return to provide care. This return was at 8:04 p.m. The total time from the call light being triggered until the NA was able to prepare to provide the care was thirty-two (32) minutes. e) On 05/09/12 at 2:45 p.m., information for Hilltop census and care levels was obtained from licensed practical nurses (LPN), Employee #46 and Employee #80 as follows: -- Hilltop Back hall census was 31, with 16 total care residents and 12 requiring 2 person assist. -- Hilltop Front hall census was 21, with 12 total care residents and 12 requiring 2 person assist. Available direct care staff were unable to provide care for dependent residents by consistently answering call lights on a timely basis. f) Residents #79 and #35 1) A dining observations were conducted in the main dining room on 05/09/12 at 11:37 a.m. At that time, there were two (2) staff present in the dining room. While meal service was observed, additional staff presented to the dining room until there were ten (10) staff serving and assisting residents. Trays were being taken from the cart directly to the residents' tables. It was noted Resident #79 and Resident #35, who were sitting at two tables close to the observation point, were served trays at 11:45 a.m. Resident #79, using her fork, took a bite from her dessert. She did not attempt to eat anything else. Resident #35 took two (2) spoons of her pureed broccoli. She did not attempt to eat anything else. Staff in the dining room did not assist or encourage the ladies to eat. At 12:15 p.m., the director of nursing was called to the dining room. The situation was explained. She voiced understanding. After an additional five (5) minutes of observation, she confirmed the observation and directed staff to provide the residents with new trays and to assist them as needed to eat. When reviewed, following the meal observation, the care plan for Resident #79 was found to include interventions for nutrition that stated: 1."Encourage resident to feed self and provide sufficient time for resident to finish meal and assist as needed." 2. "Observe and encourage intake. Offer substitutes if does not eat what is sent." The care plan for Resident #35 included an intervention for nutrition that stated "Assist to dining room for meals. Feed resident to ensure adequate intake." There was a lack of assistance provided to dependent residents. . | 2015-08-01 |