cms_WV: 11442
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11442 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2010-11-04 | 353 | F | UZ0K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of the facility-generated Form CMS-672 (Resident Census and Conditions of Residents) and facility-generated Form CMS-802 (Roster / Sample Matrix), review of the nursing staffing calculation worksheet completed by the facility for the time period of 10/10/10 through 10/23/10, review of payroll records, nursing staff postings, and assignment sheets, review of resident council meeting minutes for 10/18/10, random observations, family interview, and staff interview, the facility failed to provide sufficient direct care nursing staff on the 7:00 a.m. to 3:00 p.m. (7-3) shift to meet the assessed care needs of dependent residents and to also answer call lights in a timely manner. This practice has the potential to affect all residents in this facility. Facility census: 94. Findings include: a) According to the CMS-802 (Roster / Sample Matrix) generated by the facility from data collected through the minimum data set (MDS) assessments, there were ninety-four (94) residents living there at the time of this investigation. b) According to the CMS-672 generated by the facility from data collected through the MDS assessments: For bathing - zero (0) residents were independent, seventy-five (75) residents required the assistance of one (1) or two (2) staff, and nineteen (19) residents were totally dependent. For dressing - four (4) were independent, sixty-eight (68) residents required the assistance of one (1) or two (2) staff, and twenty-two (22) residents were totally dependent. For transferring - five (5) were independent, seventy-four (74) residents required the assistance of one (1) or two (2) staff, and fifteen (15) residents were totally dependent. For toilet use - four (4) were independent, sixty-seven (67) residents required the assistance of one (1) or two (2) staff, and twenty-three (23) residents were totally dependent. For eating - twelve (12) were independent, eighty (80) residents required the assistance of one (1) or two (2) staff, and two (2) residents were totally dependent. For bowel and bladder status, six (6) residents had urinary catheters, fifty-three (53) residents were incontinent of bladder, and thirty-eight (38) residents were incontinent of bowel. For mobility, one (1) resident was bedfast all or most of the time, fifty-five (55) were in a chair most of the time, two (2) were independently ambulatory, and thirty-six (36) ambulated with assistance or an assistive device. For skin integrity, forty-nine (49) received preventive skin care. c) Review of the facility's resident council meeting minutes for 10/18/10 revealed that residents on both wings expressed concerns that their call lights aren ' t answered in a timely manner. They stated this happens on all shifts. Review of the facility ' s resident council meeting minutes of 9/20/10 revealed that there were complaints voiced that staff would turn off call lights before their needs are met, and also that staff needs to respond to call lights instead of just walking by them. d) During random observations on 11/1/10, it was observed that the call light for room [ROOM NUMBER] was lit from 1:30 p.m. An audible alarm monitor began sounding at 1:32 p.m. The resident was observed walking from the bathroom to her bed. When she got into the bed, the alarm stopped sounding. The call light remained on. No staff intervened until 1:42 p.m. It was also observed that the call light in room [ROOM NUMBER] was lit from 3:52 p.m. until staff responded at 4:07 p.m. Two (2) staff members walked by the room, without responding to the call light. During a random observation on 11/2/10, the call light in room [ROOM NUMBER] was lit from 2:41 p.m. until staff intervened at 3:03 p.m. During random observations on 11/3/10, the call light in room [ROOM NUMBER] was lit from 9:08 a.m. until 9:23 a.m. It was then lit again from 9:35 a.m. until 9:48 a.m. At 9:48 a.m., facility LPN, employee #E99 walked to another hall and instructed a nursing assistant to go attend to the call light. The nursing assistant was heard to state, " I ' ll get it, but we really need two people on this hall. " On 11/3/10 at 9:52 a.m., when LPN #E99 was asked about the delays in responding to call lights, and whether she felt there was adequate staff, she replied, " To be honest, no. There are a lot of two-person assists on this wing. " In another brief conversation at 10:35 a.m., she stated that she feels the staff is really trying to attend to all the residents ' needs, but they just are not able to. e) When interviewed by telephone on 11/2/10 at 10:15 a.m., the complainant, who requested confidentiality stated that there is not enough staff to get the job done, causing unintentional neglect of the residents by the nursing assistants who are not able to attend to their needs in a timely manner. She felt that this was the case on all shifts, although she was most concerned with the day shift. f) The daughter of resident #8 was interviewed on 11/2/10 at 2:30 p.m. She stated that there is not sufficient staff to meet the residents ' needs. She feels this is true on all shifts. She stated that call lights are on " for a long, long, time. " She has observed this with her mother ' s light and with other residents as well. She stated that residents are often wet or soiled because there is not enough staff to provide adequate care for them. She related she is concerned that residents may fall trying to get up and do for themselves when staff does not respond for long periods of time. g) Resident #60, who is an [AGE] year old woman that has resided in the facility since 10/22/04, was interviewed on 11/2/10, immediately after the observation that it took over twenty (20) minutes for her call light to be answered, stated that it always takes a long, long time. She said that this instance was better than most. She sometimes has to holler for them or they never come at all. She stated " It makes them mad, but I can ' t help it. " Resident #13, who is a [AGE] year old woman that has resided in the facility since 9/18/90, was interviewed on 11/3/10 at 10:00 a.m. She was asked if she felt there was sufficient staff in the facility to meet the residents ' needs. She replied " No, there is not enough. " She stated she just came out of the bathroom, and that she had to wait in there for twenty (20) minutes. She stated it has been like that ever since the change of ownership. She stated " I have seen them walk right by and ignore lights. " She said she has sat in the bathroom for an hour more than once. She stated that she has complained many times, but it has done no good. h) On 11/1/10 at 3:30 p.m., facility administrator, employee #E147 provided a staffing calculation worksheet for the most recent payroll period of 10/10/10 - 10/23/10. The staffing on 7-3 shift ranged from a low of 13.5 nursing staff on 10/11/10 to a high of 19 on 10/21/10. The average total 7-3 nursing staff for the period was 15.5. i) During an interview on 11/2/10 at 2:09 p.m. facility administrator, employee #E147 reported that staffing was adjusted for census. The general budgeted staffing levels were from 2.89 to 2.92 hours per patient per day (PPD). With a census of 94 the staffing would therefore range from 271.66 to 274.48 hours. The total nursing hours on the staffing calculation worksheet ranged from a low of 246.25 on 10/14/10 to a high of 323.5 on 10/21/10. The average total nursing staff hours for the period was 270.0. During an interview on 1/3/10 at 11:20 a.m., facility director of nursing (DON) stated that although the staffing may be adjusted for census or also at times for acuity, the usual staffing is four (4) nursing assistants and three (3) licensed nurses for each wing, for a total of eight (8) nursing assistants and six (6) licensed nurses. j) During an interview on 11/4/10 at 9:05 a.m., the facility director of nursing (DON) provided call light audit information for 10/10. She stated that the audits were to be compiled for quality assurance study in November, but that the information was not yet summarized for that purpose. Each form was found to contain fields for entry of date, room, time light went on, time light was answered, and signature. A review of the audit sheets found they covered the period of 10/12/10 to 10/31/10 as follows: 10/12/10 5 audits done, 10/13/10 2 audits done, 10/14/10 no audits done, 10/15/10 5 audits done, 10/16/10 4 audits done, 10/17/10 no audits done, 10/18/10 3 audits done, 10/19/10 1 audit done, 10/20/10 13 audits done, 10/21/10 9 audits done, 10/22/10 2 audits done, 10/23/10 11 audits done, 10/24/10 5 audits done, 10/25/10 11 audits done, 10/26/10 8 audits done, 10/27/10 9 audits done, 10/28/10 7 audits done, 10/29/10 8 audits done, 10/30/10 8 audits done, 10/31/10 7 audits done. This represents six (6) call lights timed each day. An interview was conducted with " A " wing facility registered nurse (RN), employee #E116, on 11/4/10 at 9:15 a.m. She was asked to briefly explain her role in the call light audits. She indicated that the nurses write down the time they observe a call light come on, and the time it is answered. She stated that if it goes too long, she answers it herself, because she doesn ' t want the resident to wait too long. An interview was conducted with " B " wing facility registered nurse (RN), employee #E47, on 11/4/10 at 9:22 a.m. She was asked to briefly explain her role in the call light audits. She indicated that the nurses write down the time they observe a call light come on, and the time it is answered. Each nurse is to do two (2) audits per shift. She stated that if the light is unanswered for ten (10) minutes, she answers it herself. k) Review of the nursing staffing on 11/1/10 and on the staffing calculation worksheet (for the time period of 10/10/10 to 10/23/10) revealed that, while the facility met the State-mandated minimum of 2.25 hours of direct nursing care per resident per day, the staffing levels deployed on the 7-3 shift on 11/1/10 were determined to be inadequate to meet the assessed care needs of all 94 of the facility's residents and also allow staff to answer call lights in a timely manner. | 2014-03-01 |