| 49 |
GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER |
125004 |
3-3420 KUHIO HIGHWAY, SUITE 300 |
LIHUE |
HI |
96766 |
2016-10-28 |
241 |
D |
0 |
1 |
U50511 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of their individuality. Dignity also means interactions with residents such that facility staff carry out activities that assist the resident to maintain and enhance their self-esteem and self-worth. This facility failed to ensure staff responded in a timely manner to a resident's request for assistance for 2 of 31 residents (Resident #183 and Resident #171) in the Stage 2 sample. Findings include: 1. Resident #183 was admitted to the facility as a short stay resident and was receiving skilled rehabilitation services. During an interview with Resident #183 on 10/26/16 at 8:07 AM, they stated, To be perfectly honest, I think they are short staffed. I get up to use the bathroom, but I'm not allowed to get up by myself because of my fracture and they don't want me to fall. And I don't want to have accidents either, but sometimes, I wait, and I wait, and I wait, and I've had a couple of accidents--yes, shi-shi (urine) or bowels, either one. They said because they couldn't wait for staff to attend, they get out of bed, when I'm really desperate. Resident #183 said because of the long wait times, they have had four accidents. When asked how staff responded when they had these accidents, they said, Not especially anything and I tell them, oops sorry. A lot of times, it's right at the toilet and I can't get there fast enough and I know it's coming. When you gotta go, you gotta go, and they're not here for me. They're busy elsewhere, which is understandable, a lot of other people are here. They're very nice here, don't get me wrong. But, whether it's the early morning, late at night, sometimes there's not enough of them and that's the only reason why I think they're short handed. During an interview with the MDS-C on 10/27/2016 at 1:28 PM, they said Resident #183 scored a 15 on their BIMS, and is alert and oriented x 3 based on the MDS ARD of 10/11/16. They stated this resident is totally continent. On 10/28/2016 at 7:52 AM, a re-interview with Resident #183 was done. They reiterated there is a problem with the shortage of staff and, the primary reason is because they're having to attend to others. They said it was their honest observation being admitted at this facility and it was undignified for them having these accidents of soiling themselves. 2. Resident #171's family member was interviewed on 10/25/16 at 1:21 PM. Resident #171 was admitted on [DATE] for skilled rehabilitation services after an acute hospital stay. During the interview, the family member stated the resident was not treated with respect and dignity and stated it was because of how a nurse's aide did not want to assist the resident to be toileted. The family member said it recently happened when the resident had to wait until after the lunch was over. The family member stated as a result, the family member had to assist the resident to be toileted and they had soiled themselves. On 10/28/16 at 8:58 AM, during another interview with Resident #171's family member, the family member reiterated the nurse's aide who did not want to toilet the resident also walked down the hall the opposite way, just like ignoring us. The family member said, I was going to put them on, but the therapist came and took the Resident #171 and had to help me, because (the aide) said the residents are eating. But already Resident #171 wanted to make, so it came out, all on the bed because their diaper was leaking and the wheelchair was all with the shi-shi (urine), and the therapist took Resident #171 to the bathroom to clean them up and put on the diaper. (The aide) was in the next room, and said can you take them because they want to get out of bed to go to the bathroom, but we're still having lunch, so have to wait. Resident #171 came all wet because they couldn't wait. The family member said afterward, another nurse's aide came to help change the soiled bedding. The family member said it was upsetting, they felt ignored, and because Resident #171 all wet, the bed and the chair all soaked like that, Resident #171 got angry, so I got angry. On 10/28/2016 at 9:24 AM, interview with the speech therapist (ST #1) was done. ST #1 verified the family's member's account when Resident #171 had recently transferred themselves to the chair and was soiled. ST #1's said the reasoning was because the aide for Resident #171 had been attending to another resident who fell , which coincided with Resident #171's request to be toileted. ST #1 said they reported it to the day charge nurse, LN #3, and verified the aide was attending to the other resident while they stepped in to help Resident #171. On 10/28/2016 at 9:38 AM, LN #3 confirmed that ST #1 had told them that Resident #171 was all wet and (the aide) was also going to do Resident #171, change them also, but therapy was the one who had to change them because they went there to do the therapy early. LN #3 said they did not go to speak with Resident #171 nor to the family member after the incident happened. LN #3 was asked whether they thought about providing an explanation to the resident and/or family member, but LN #3 stated, No, I was only talking to the therapy. On 10/28/2016 at 9:52 AM, RCM #2 said if the charge nurse was aware of what happened, the charge nurse, is supposed to investigate with the family, ask the family, and the charge nurse is supposed to inform me or the DON. RCM #2 acknowledged LN #3 should have done that, and understood why the family member felt there was no respect or dignity afforded to Resident #171, after having soiled themselves when the family member asked for staff assistance. |
2020-09-01 |