| 40 |
THE MEADOWS ON UNIVERSITY |
355024 |
1315 S UNIVERSITY DR |
FARGO |
ND |
58103 |
2018-12-06 |
565 |
E |
1 |
0 |
PNS511 |
> Based on information provided by the complainant, observations, review of monthly Resident Council meeting minutes, and resident, family, and staff interviews, the facility failed to actively seek a resolution to resident grievances related to delayed responses to call lights expressed by 9 of 10 sampled residents (Residents #1, #2, #3, #4, #6, #7, #8, #9, and #10). Failure to act upon the resident/family grievances regarding staff response time to call light resulted in continued dissatisfaction. Findings include: The facility failed to provide a copy of their policies addressing call lights and resident and/or family/representative grievances upon request. Information provided by the complainants indicated they had been contacted by residents who expressed frustration waiting for staff to respond to their call lights and/or who experienced pain/discomfort related to skin breakdown due to incontinence. Observations showed the following: * On the morning of 12/06/18, a bathroom call light remained unanswered from 8:02 a.m. until 8:24 a.m. (22 minutes). * 12/06/18 at 8:25 a.m., Resident #3 lying in bed. His call light, hanging over the top of the night stand, and not within reach. * 12/06/18 at 10:35 a.m., Resident #3 lying in bed. His call light, hanging over the top of the night stand, and not within reach. Resident reached for his call light and was unable to access it. A sign, posted on the wall, stated, Please keep call light clipped to the sheet and within reach. Review of Resident Council Meeting minutes, dated June-November (YEAR), occurred on 12/06/18. The meeting minutes identified residents voiced the following concerns : * August, . certified nursing assistants (CNAs) . make roommate wait. Roommate can't use (his/her) call light. CNA refused to help another pt (patient) . * September, . CNAs don't answer call lights timely in the a.m. * October, . (Resident) - slow call lights concern form filled (out). Resident and Family/Representative interviews identified the following: * 12/05/18 at 5:05 p.m., Resident #10 (identified by the facility as interviewable) stated, Last night, I sat all night in a dirty diaper. The call light was unplugged. That's a long time . all night. That's a long time to have a dirty diaper. No one was in here at all last night. They kind of ignore me. I don't know if they don't like me or what. * 12/05/18 at 5:30 p.m., Resident #9 (identified by facility as interviewable) stated, I've had to wait 45 minutes for staff to answer my call light. It took so long that I wet my pants. * 12/05/18 at 5:42 p.m., Resident #6's family member reported often waiting 15-20 minutes for staff to respond to Resident #6's call light. The family member also reported Resident #6 is a fall risk. * 12/05/18 at 5:55 p.m. Resident #1 reported often having to wait for over an hour to use the bed pan. Resident #1 stated, I limit the amount of water I drink depending upon who is working, because I know (staff) will take a long time to answer my light. Resident #1 also reported having wet the bed waiting for staff to answer the call light. * 12/05/18 at 6:10 p.m. Resident #2 stated, I have to wait a long time, 60-90 minutes sometimes, for (staff) to answer my call light. * 12/05/18 at 6:15 p.m., Resident #4 (identified by the facility as interviewable) reported waiting multiple times, for up to an hour, for staff to answer her call light. Resident #4 then described one occurrence in detail, where she turned on her call light for a pain pill. Resident #4 reported a staff member entered her room, turned off her call light, told her she would notify the nurse, and left the room. A nurse offered her a pain pill one hour and forty-five minutes later. Resident #4 then stated she continued to have pain and turned her call light on several times throughout the evening. In frustration, she called a family member, asking them to call the facility in an effort to get someone to answer her light. * 12/06/18 at 7:50 a.m., Resident #10 pointed to her call light and stated, I rang the bell here. I finally got up and went in there (bathroom). I rang the bell in there. Took them forever. About twenty-five minutes, I was sitting there this morning. I'm so discouraged. * 12/06/18 at 8:00 a.m., Resident #7 (identified by facility as interviewable) stated, I put my call light on one day and had to wait 45 minutes before staff answered the light. Resident #7 reported being told staff failed to answer the light because a physical therapist was present in the room. * 12/06/18 at 8:15 a.m., Resident #8 (identified by facility as interviewable) reported waiting for up to one hour for staff to answer the call light. * 12/06/16 at 10:15 a.m., Resident #4's family member confirmed Resident #4 had called them at home asking them to contact the facility for assistance. * 12/06/18 at 10:50 a.m., Resident #10 shifted her weight as she laid on the bed and stated, My butt is so sore! The (staff) are getting so disgusted checking my diaper. I hate to do it (pointed towards call light). During a staff interview on 12/06/18 at 10:55 a.m., a CNA (#4) stated Resident #10 puts on (her) call light. If we're helping someone else, she will self-transfer to (the) bathroom. During a staff interview on 12/06/18 at 2:45 p.m., when asked the facility's expectation regarding staffs' response to call lights, an administrative nurse (#1) stated, I believe it's two minutes. Failure of the facility to act upon the resident/family grievances regarding call light response times resulted in resident incontinence/possible skin breakdown, safety concerns due to residents self-transferring, and continued frustration and dissatisfaction. |
2020-09-01 |