cms_NE: 8029
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8029 | GOOD SAMARITAN SOCIETY - ATKINSON | 285177 | 409 NEELY STREET | ATKINSON | NE | 68713 | 2014-02-27 | 353 | F | 0 | 1 | 03FZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C. Confidential interviews revealed the following complaints regarding lack of sufficient nursing staff: - On 2/24/14 at 10:22 AM, a resident indicated they are short of help all the time. The resident further revealed timing a call light at 2 hours and 15 minutes before it was answered. - On 2/25/14 at 9:13 AM, a family member indicated the facility was short of staff. The family member revealed finding the resident's bathroom a mess quite a few times, and at times finding the resident unclean. The family member further indicated staff did not take the resident to the noon meal 1 day, and therefore, the resident was taken to the dining room by a family member who also fed the resident. The following complaints were received regarding lack of sufficient nursing staff: -During a confidential family interview on 2/25/14 at 10:01 AM, a family member stated, The staff are overworked and whenever new staff is hired they leave right away because they are expected to work so many hours. I have witnessed call lights on in the evenings for over 45 minutes. In addition, family member indicated their (gender) recently had an order for [REDACTED]. The family member stated, I refused to pay for the treatment as she never really received it. -During a confidential resident interview on 2/24/14 at 1:43 PM, the resident stated, There is not enough staff in the place; I can't have as many baths as I would like and there are never enough staff available to get you up or put you to bed when you want. -During a confidential family interview on 2/24/14 at 2:49 PM, the family member indicated call lights were on for over 30 minutes in the evening and due to lack of sufficient staff, snacks were rarely passed on the evening shift. D. Observations of untimely call light response and failure to provide toileting assistance revealed the following: Observations of Resident 54 on 2/26/14 revealed the following: -At 8:48 AM, the resident's call light was on and resident was seated in wheelchair in the room. -At 9:10 AM, the resident propelled wheelchair into the doorway of room and the resident looked up and down the hallway. The resident's call light remained unanswered. -At 9:14 AM, the resident remained in the doorway of room, the Activity Director (AD) walked by the resident and resident called out for help. The AD assisted the resident back into the room and closed the door. -At 9:15 AM, Resident 54's call light was turned off. (37 minutes after the resident had turned on the call light for assistance) Observations of Resident 20 on 2/26/14 revealed the following: -At 8:58 AM, the resident's call light was on and the resident was seated in room in a wheelchair. The resident indicated call light had been turned on as the resident needed to use the bathroom. -At 9:11 AM, NA-D and NA-C entered Resident 20's room, closed the door and turned off the call light. -At 9:30 AM, Resident 20 remained seated in wheelchair in room. Resident 20 was crying and stated, They still haven't taken me to the bathroom. The resident's call light was turned back on. -At 9:45 AM, NA-D entered Resident 20's room, closed the door, and turned off Resident 20's call light (47 minutes after Resident 20 initially turned on the call light to seek assist with toileting). -During an interview on 2/26/14 from 10:08 AM to 10:10 AM, NA-C confirmed Resident 20's call light had been turned off at 9:04 AM. NA-C indicated the resident needed to go to the bathroom and NA-D was going to assist Resident 20. NA-C left Resident 20's room and was unaware Resident 20 was never toileted. -During an interview with NA-D on 2/26/14 from 11:05 AM to 11:10 AM, NA-D confirmed Resident 20 was not taken to the bathroom until call light was turned off at 9:45 AM. (Surveyor ) -During observation on 2/26/14, the call light above the door of Resident 58 ' s room was observed to be activated at 7:55 AM. There was a housekeeping cart parked outside the room and the housekeeper was working in the hallway. At 8:08 AM the call light for the resident room across the hall was activated, and Resident 58 ' s call light remained on. At 8:09 AM a Nursing Assistant (NA) entered the room across the hall, and at 8:10 AM another NA entered the same room. Resident 58 ' s call light remained on. At 8:13 AM (18 minutes after the call light was noted to be activated), the housekeeper entered room [ROOM NUMBER] asking Are you ready to go out? The housekeeper wheeled Resident 58 out of the room and toward the dining room. -During interview on 2/26/14 at 1:50 PM, Resident 58 verified waiting an hour for call light to be answered this morning. The resident indicated call light response has been discussed at Resident Council meetings at least as far back as November. F. During an interview on 2/27/14 from 10:10 AM to 10:30 AM, the Quality Assurance (QA) Coordinator identified facility staff was aware of resident and family's concerns regarding call light response time. The QA Coordinator identified random audits were supposed to be completed of call light response times, but there was no documentation that these audits had been completed. LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on observations, record review, resident, family and staff interview; the facility failed to provide sufficient staffing to meet the resident ' s needs related to: 1) Provision of baths in accordance with resident choices and as indicated by care plans for 2 residents (residents 41 and 29); 2) Provision of timely toileting assistance for Resident 20; 3) 3 Confidential family and 2 confidential resident interviews regarding shortage of nursing staff on duty; and 4) Untimely call light response for Residents 54, 20 and 58. Facility census was 45. Findings Are: A. Review of Resident Council Meeting Minutes revealed the following: -August 20th, 2013; residents voiced there was not enough staff and that call lights were not being answered timely. -September 17th, 2013; residents voiced there was not enough staff and call lights were not being answered timely. Residents go on to state baths were not being given with any consistency. -October 22nd, 2013; residents voiced staffing remains an issue. -November 19th, 2013; residents voiced call lights were not answered timely and that they were aware there was a shortage of staff. -December 17th, 2013; residents voiced call lights were not answered timely and they were aware there was a shortage of staff. -February 25th, 2014; residents voiced call lights were not answered timely. B. The following complaints were received due to lack of sufficient staff and baths not being provided as care planned: - During an interview on 2/24/14 at 1:54 PM with Resident 29, it was revealed Resident 29 receives one bath a week and would like a bath more often. Resident 29 stated the resident has voiced this to staff but was told there is not enough staff for the resident to receive a second bath in the week. - A review of Resident 29's care plan, dated 9/4/13, revealed an intervention for the resident to have two baths a week. - A review of the bath schedule for the months of December, January and February revealed Resident 29 received 4 baths in December (for Resident 29 to have 2 a week 9 baths would be given), 5 baths in January (for Resident 29 to have 2 a week 9 baths would be given), and 4 baths in February (for Resident 29 to have 2 a week up to the present date in February 7 would be given). - During an interview on 2/25/14 at 11:23 AM with Resident 41, it was revealed Resident 41 is to receive 2 baths a week but due to the facility not having enough staffing has at times only received 1 bath a week. - A review of Resident 41's care plan, dated 1/22/14, revealed an intervention for the resident to have 2 baths a week. - A review of the bath schedules for the months of December, January and February revealed Resident 41 received 7 baths in December (for Resident 41 to have 2 a week 9 baths would be given), 6 baths in January (for Resident 41 to have 2 a week 9 baths would be given) and 6 baths in February (for Resident 41 to have 2 a week up to the present date in February 7 would be given). - During an interview on 2/26/14 at 4:17 PM with a confidential staff member, it was revealed that at times the bath aide is required to complete nurse aide duties other than providing baths when there was a shortage of staff. The staff member stated that at times the bath aide is scheduled as a nurse aide and no bath aide is scheduled during these shifts. It was further revealed that in instances when the bath aide was required to perform other duties, residents did not receive their scheduled baths. - During an interview on 2/26/14 at 4:45 PM with the Director of Nursing and Administrator , it was verified the facility did have a practice of having the bath aide perform other nurse aide duties when the facility was short staffed. | 2017-11-01 |