cms_SC: 8358
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8358 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-05-30 | 241 | E | 1 | 0 | FG7811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record reviews and interviews, the facility staff failed to provide care in a manner that maintained and enhanced dignity for 3 of 5 sampled residents (Residents #2, #3, and #4) and for 1 of 4 randomly selected residents listed as interviewable by the facility (Resident D). The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set Assessment with an Assessment Reference Date of 5/21/13 revealed Resident #4 had a Brief Interview for Mental Status score of 15, indicating s/he had been cognitively intact at the time of the assessment. According to the assessment, the resident required extensive assistance with two person physical assistance for transfers and toileting. Review of the 5/8/13 hospital Discharge Summary revealed information that Resident #4 .is receiving physical therapy twice daily. Today s/he was ambulatory with physical therapy for 14 feet x 2. I observed the patient with standby assistance to the restroom earlier and s/he was ambulating well. Weightbearing as tolerated with the rolling walker . Orders on discharge include physical therapy, ambulate weightbearing as tolerated with the rolling walker . Review of a Bladder Re-Training assessment dated [DATE] revealed Resident #4 was continent. Review of the Interim (Admission) Care Plan revealed an entry for Alteration in ADL (Activities of Daily Living) ability, Requires assist with .ambulation, .transfer . toilet use. The goal was that Resident will have needs met and included interventions that had been checked, such as .use adaptive equipment as ordered . During a phone interview on 5/28/13 at 4:00 PM, Resident #4 reported that on May 18, 2013 (Saturday night a week ago), s/he needed assistance to the bathroom and a Certified Nursing Assistant (CNA) came in and said that s/he would not be able to help, and that the resident would have to wear a diaper since it was just that CNA and a nurse working. Resident #4 stated that it took 45 minutes for the CNA to answer the call light, and that s/he definitely didn't want a diaper, (this was her/his main complaint). Resident #4 stated s/he told the CNA that s/he could get up, but that the CNA stuck a diaper on her/him anyway. According to Resident #4, there were other times when it took 15-45 minutes for someone to come and assist her/him to the toilet, and by that time s/he had urinated on her/himself. During a phone interview on 5/28/13 at 3:28 PM, a family member stated Resident #4 had a raised toilet seat in the bathroom and that this raised toilet seat kept getting moved since the residents in the adjoining room could not use the toilet with the raised seat. According to the family member, Resident #4 had a weak bladder and when s/he had to go, it was hard to find someone to take her/him to the bathroom at night. The resident's walker and wheelchair were also placed where s/he couldn't reach it to take her/himself to the bathroom. According to the family member, the resident had been taking her/himself to the bathroom at night due to lack of help. The family member also stated s/he had been there at the facility visiting either every day or every other day. In the evenings, the call lights would go off for 30-40 minutes without anybody coming to answer them. This family member also said that s/he took the diaper off the resident her/himself and that s/he was upset about this and because there was a package of diapers in the room, to be used for an alert, oriented, continent resident. This family member also expressed concerns that the resident had been asked to use the bedpan instead of getting the assistance s/he needed to transfer to the toilet. According to the family member, a CNA told them s/he was not aware of the type of surgery that had been done, or the type of assistance that was needed to transfer the resident. The family member stated that Resident #4 brought up concerns with staffing to Registered Nurse (RN) #1, and that RN #1 said that they had a hard time getting staff to work at night, and said to speak with the Administrator. During a phone interview on 5/29/13 at 11:39 AM, RN #1 stated s/he had not been made aware of any complaints for Resident #4 related to call lights, staffing, toileting, or any incidents with a diaper. According to RN #1, the census had been low, so there was a decreased amount of staff at night, but the facility was still in compliance with staffing. RN #1 stated s/he had been told (after the resident switched rooms), that one of the reasons the resident moved was because the residents in the adjoining room would move her/his toilet seat. During an interview on 5/29/13, CNA #1 stated that s/he remembered Resident #4, and that s/he usually worked 7 AM-7 PM and had been off on 5/17, 5/18, and 5/19. CNA #1 was not aware of any of the above concerns expressed by the resident. CNA #1 stated that Resident #4 seemed mobile. When asked about delays in answering the call lights, CNA #1 stated that some aides were busy and it took longer to get to the call lights, but that they got to them as soon as possible. When asked what a timely response would be to a call light, s/he stated that within 2-3 minutes but no more than 5 minutes. When asked how staff find out about the care or assistance residents need, CNA #1 stated that ADL care sheets are placed after admission inside the resident's room on a door. The ADL sheets included information on diet, toileting, mobility, and transfer assistance. CNA #1 stated that staff could also ask a nurse if they had a question. During an interview on 5/30/13 at 2:00 PM, Licensed Practical Nurse (LPN) #1 stated that s/he was not aware of any concerns related to the staff not answering call lights or assisting residents with toileting; and had not heard any complaints from any residents or families. LPN #1 stated s/he was talking to Resident #4 one day and asked how s/he was doing. LPN #1 said that Resident #4 didn't go into details, but told her/him that there was an issue with a CNA. The resident told LPN #1 that s/he had to use the restroom frequently and that s/he didn't want to wear a brief. LPN #1 stated that because the resident said this, s/he had met with the CNAs and gave them this information. The nurse told the CNAs that the resident didn't need help getting up, just needed someone in the room to assist her/him. During a phone interview on 5/30/13 at 9:42 AM, RN #2 stated that s/he was aware of an incident in which a CNA put a diaper on Resident #4. A CNA involved told RN #2 that s/he had come to assist the resident onto the bedpan, and found a brief was already on the resident. It was thought that since the resident was refusing to get up to go to the bathroom, a CNA had placed the brief on the resident so s/he wouldn't wet her/himself and be uncomfortable. According to RN #2, the CNA said that s/he had assumed after seeing the brief that the resident was having incontinent episodes, and since the resident didn't tell the CNA s/he did not need the brief, s/he thought it was okay. According to RN #2, it was a miscommunication and s/he had apologized to the resident. RN #2 stated that once the resident was moved to another room, the resident would get up and use the bathroom. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 5/14/13 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #2 was cognitively intact at the time of the assessment. According to the assessment, the resident required extensive assistance with two person physical assistance for transfers. During a phone interview on 5/28/13, Resident #2's family member stated that one time during the day, it took 2 hours for the nurse to answer the resident's call light. The family member also complained that during shift change, from approximately 6:45 PM to 7:15 PM, call lights were not answered and that a staff member told them that they don't answer the call lights during shift change. One evening near the change of shift, when the resident wanted to get into bed, the family member stated the call light wasn't answered and s/he had wanted to get the resident into bed before s/he left. Another family member also reported that another resident, was observed in a wheelchair crying. When the family member left 2 hours later, the resident was still crying, so they stopped to ask him/her what was wrong and the resident said that s/he needed to be changed. During an interview on 5/29/13 at 2:26 PM, the Social Services Coordinator stated that while working on Mother's Day (S/he had been the manager on duty that weekend), s/he had stopped in to say hello to Resident #2. During conversation, Resident #2 reported that s/he had to wait quite awhile to get a call light answered. According to the Social Services Coordinator, s/he had asked Resident #2 if s/he had told the nurse. The resident said no, because then s/he would have said something they wouldn't have liked. The Social Services Coordinator stated the resident saw the nurse passing medication in the hall while the call light was going off, but didn't say anything and just went back into his room and waited until someone came. According to the Social Services Coordinator, during care plan meetings and through chats, s/he sometimes hears concerns that there aren't enough staff or that call lights aren't answered timely. When asked if these were documented in the Care Plan meeting notes, s/he said they weren't. According to the Social Services Coordinator, when asked if they would like to file a formal grievance, the reply would be that the residents didn't want to get anyone in trouble. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment with an ARD of 4/24/13 revealed a BIMS score of 13 which indicated Resident #3 was cognitively intact at the time of the assessment. According to the assessment, Resident #3 was totally dependent on staff with one person physical assist for toileting; and was always incontinent of bowel and bladder. Review of a Bladder Re-Training Assessment for Resident #3 dated 1/24/13 revealed information that included the following: -Is the resident aware of need to urinate?- Yes -Does the resident have memory recall? - No -Is the resident able to request assistance? -Yes -Is resident able to self-transfer? - No Mental Status and ability to participate in retraining: A&O (Alert and Oriented) X 3 with slight confusion at times. During an interview on 5/29/13 at 10:05 AM, Resident #3 stated that s/he puts on the call light and can't get anyone to clean him/her. The resident stated that s/he didn't know what to do. When asked how long it took for staff to clean him/her up, the resident stated, a couple of hours after I put on my light. When asked how s/he knew it took hours, the resident stated that s/he didn't have a watch to tell time. When asked how often this happens, the resident said, It happens every day, mostly at night. The resident verified s/he wore a brief. When asked how this made him/her feel the resident stated that it has upset him/her. Review of Resident #3's Care Plan revealed an entry dated 2/6/13 that included information that .Resident often requests for brief to be changed when it is dry. A handwritten entry stated, Frequently puts call light back on before staff can walk to Nurses Station. A handwritten intervention stated, Increase activity visits as able. During an interview on 5/29/13 at 3:05 PM, the Interim DON stated that during the May 22, 2013 staff meeting, several concerns were addressed that included call light timeliness and customer service in general. When asked if there was a written Quality Assurance plan of action related to call lights or any audits, the Interim DON stated there was nothing documented for this. According to the Interim DON, staff had mentioned concerns with Resident #3 being rather lonely and wanting attention. According to CNA staff, the resident was not being left wet. The Interim DON stated CNAs had even brought dry briefs the resident had requested they change. During this interview it was mentioned that a surveyor had observed a call light being on for 10 minutes. During Initial Tour on 5/28/13, between 8:50 AM and 9:00 AM (for 10 minutes), a surveyor observed the call light on in room [ROOM NUMBER]. Two CNAs passed by and a med nurse was in the hall during this time frame before a staff member came and answered the light. According to the resident, the light just came on itself and there was no assistance needed. During an interview on 5/30/13 at 9:30 AM, concerns related to call lights and toileting were discussed. The Interim DON provided documentation of a Summary of Continuing Education Meeting for staff dated 5/22/13 that included call lights as a concern. According to the Interim DON, in addition to the inservice, s/he had talked with management staff about this. The Interim DON stated that s/he had stayed later in the evenings to monitor call light response and that the Regional President also made rounds when s/he came through the facility. When asked for any documentation of any monitoring, s/he stated there was none but that s/he could get statements of this. Concerns related to dignity were noted for 2 of 4 randomly selected residents listed as interviewable by the facility. During an interview on 5/29/13 at 10:00 AM, Resident D stated that s/he had been there 5 months and during this time there had been delays at times where the call lights weren't answered for 10-30 minutes, with weekends and evenings being the worst times. The resident stated s/he used to have a room mate that said s/he was going to complain about it. According to Resident D, waiting 30 minutes is too long and a lot of times s/he has had to go to the bathroom and not made it. When asked why there was a delay, the resident said that from his/her opinion there wasn't a good system in place. The resident said that when CNAs worked in the dining room there was no one on the hall, and residents could be stuck for a long time during meals. Review of Resident Council Meeting Minutes on 5/29/13 at 2:53 PM revealed documentation that residents had concerns with the amount of time it took for staff to answer their call lights in January 2013, March 2013, and April 2013. A form that addressed concerns raised in Resident Council Minutes revealed documentation dated 5/2/13 relative to the call light concerns that said, Inservice was held 2/12/13 that addressed the issue of response time to call lights. A second sheet dated 5/6/13 stated, Inservice held 5/22/13 addressing call light wait times. Random night rounds also to be done once a week for two weeks. | 2016-05-01 |