| 11504 |
SALEM CENTER |
515071 |
255 SUNBRIDGE DRIVE |
SALEM |
WV |
26426 |
2010-09-23 |
311 |
E |
|
|
5AUJ11 |
. Based on record review and staff interview, the facility failed to provide daily restorative nursing services for residents designated to receives those services. Record review revealed specific written plans to meet specific goals for residents in the restorative nursing program. However, restorative aides were, at times, pulled to work the floor in the capacity of a nursing assistant due to staffing shortages, leaving the restorative nursing services undone. During interviews with certified nursing assistants (CNAs) conducted on 09/22/10, seven (7) of eight (8) CNAs interviewed reported they do not follow the restorative nursing plan; rather, they perform range of motion to restorative residents the same as they do to all dependent residents during the performance of activities of daily living. Resident identifiers: #10, #12, #49, #56, #57, #59, #61, #65, #70, #73, #77 #81, and #82. Facility census: 101. Findings include: a) Resident #10 Review of the Restorative Nursing Program (RNP) Flow Sheet, found in the restorative book for September 2010, revealed he was to "perform active assist range of motion (ROM), bilat (bilateral) upper ext (extremities) all joints 3 sets of 20 (twenty) reps (repetitions) daily." Restorative staff documented having provided this service on only nine (9) of the first twenty (20) days in September (9/2, 9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - b) Resident #12 Review of the RNP Flow Sheet for September 2010 revealed Resident #12 was to receive "Active ROM (range of motion) ex (exercise) 2 sets 15 reps (repetitions) in seated position (heel / toe raises, seated marches, knee extension / flexion, hip abduction / adduction) daily". Restorative staff documented having provided this service on only nine (9) of the first twenty (20) days in September (9/7, 9/8, 9/9, 9/10, 9/12, 9/13/, 9/14, 9/15, 9/16). Resident #12 was also to "Ambulate /c (with) rolling walker - contact guard of 1 assist to daily tolerance / distance." Restorative staff documented having provided this service on only six (6) of the first 20 (twenty) days in September (9/7, 9/8, 9/9, 9/10, 9/15/ 9/16). - c) Resident #49 Review of the RNP Flow Sheet for September 2010 revealed Resident #49 was to receive "active assist ROM 3 sets 15 reps each (seated marches, knee ext while seated, hip abduction / adduction)" and "Ambulate /c rolling walker - min (minimum) assist of 1 (symbol for increase) to 50 ft or more as tolerated." Restorative staff documented having provided this service on only four (4) of the first twenty (20) days of September, with four (4) refusals. Dates documented for both plans were 9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16. - d) Resident #56 Review of the RNP Flow Sheet for September 2010 revealed Resident #56 was to receive: "Bilat (bilateral) lower ext (extremity) - active ROM 2 sets x 15 reps ... (seated marches, hip abduction / adduction, knee extension / flexion, heel / toe raises - dorsal / plantar flexion)." Restorative staff documented having provided this service on only seven (7) of the first twenty (20) days of September (9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). Also, review of the RNP Flow Sheet for this time period revealed she was to: "Ambulate /c rolling walker (10 - 30 ft) - verbal cue to keep walker @ correct distance in front of her." Restorative staff documented having provided this service on only three (3) of the first twenty (20) days of September, with three (3) refusals (9/4, 9/7, 9/8, 9/14, 9/15, 9/16). Also, review of the RNP Flow Sheet for this time period revealed she was to have: "Active Assist ROM (R) (right) upper ext (extremity) - 3 sets 15 reps... Active ROM (L) (left) upper ext - 3 sets 15 reps." Restorative staff documented having provided this service on only seven (7) of the first 20 (twenty) days of September (9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - e) Resident #57 Review of the RNP Flow Sheet for September 2010 revealed Resident #57 was to receive: "Active ROM - 3 sets 15 reps... passive ROM LUE (left upper extremity) and (L) hand - 3 sets 15 reps... wash & dry (L) hand - remove splint q (every) day - report any skin issues to nurse." Restorative staff documented having provided this service on only eight (8) of the first twenty (20) days of September (9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - f) Resident #59 Review of the RNP Flow Sheet for September 2010 revealed Resident #59 was to maintain bilateral upper extremity strength and "use 7 lb therapy bar during course of ADL (activity of daily living) - 3 sets - 20 reps or to tolerance." This treatment was to have begun on 09/21/10. During an interview with Employee #54 on 09/22/10 at 11:30 a.m., she said it was not begun on 09/21/10, as staff did not know where the therapy bar was kept in the physical therapy department. - g) Resident #61 Review of the RNP Flow Sheet for September 2010 revealed Resident #61 was to: "Ambulate up to 300 ft /c rolling walker - contact guard assist (may continue after resting) for (symbol for increased) ambulation if desired." Restorative staff documented having provided this service on only eight (8) of the first twenty (20) days of September (9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). Also, she was to have: "Bilat (bilateral) lower ext (extremity) 2 sets 15 reps AROM (active range of motion)... 2 lb ankle weight (seated marches, knee extension / flexion, hip abduction / adduction, dorsal / plantar circles... heel / toe raises." Restorative staff documented having provided this service on only seven (7) of the first twenty (20) days of September on (9/4, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - h) Resident #65 Review of the RNP Flow Sheet for September 2010 revealed Resident #65 was to: "Ambulate 400 ft + (plus) /c supv (supervision) - no assistive device." Restorative staff documented having provided this service on eleven (11) of the first twenty (20) days of September (9/1, 9/2, 9/4, 9/7, 9/8, 9/9, 9/10, 9/12, 9/14, 9/15, 9/16). Also, she was to have: "AROM bilat lower ext - cues may be necessary (heel / toe raises, knee extension / flexion, hip abduction / adduction) 2 sets - 15 reps." Restorative staff documented having provided this service on only eleven (11) of the first twenty (20) days of September (9/1, 9/3, 9/4, 9/7, 9/8, 9/9, 9/10, 9/12, 9/14, 9/15, 916). She was also to receive: "Active ROM bilateral upper ext 3 sets - 20 reps... verbal cues /c ADL's (activities of daily living) - dressing / grooming / toileting." Restorative staff documented having provided this service on only nine (9) of the first twenty (20) days of September (9/4, 9/7, 9/8, 9/9, 9/10, 9/12, 9/14, 9/15, 9/16). - i) Resident #70 Review of the RNP Flow Sheet for September 2010 revealed Resident #70 was to have: "Left upper ext all planes active ROM 3 sets - 20 reps." Restorative staff documented having provided this service on only eight (8) of the first twenty (20) days of September (9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16), with one (1) refusal. - j) Resident #73 Review of the RNP Flow Sheet for September 2010 revealed Resident #73 was to: "Ambulate /c rolling walker - CGA (contact guard assist) 300+ ft ... Active ROM BLE ex (bilateral lower extremity exercise) - heel / toe raises, seated marches, knee extension, hip abduction / adduction... Active ROM ex (exercise) - bilat upper ext all planes 3 sets - 30 reps." Restorative staff documented having provided these service, which included two (2) days when the resident was out of the facility, on only nine (9) of the first twenty (20) days of September (9/1, 9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - k) Resident #77 Review of the RNP Flow Sheet for September 2010 revealed Resident #77 was to have" "Active ROM ex (L) upper ext 3 sets - 15 reps use 2 lb wgt (weight) if possible... Active assist ROM (R) upper ext 3 sets - 15 reps... Bilat lower ext active ROM 3 sets - 15 reps (ankle pumps, knee extension, hip flexion, seated marches, hip abduction / adduction." Restorative staff documented having provided these service on only seven (7) of the first twenty (20) days of September (9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - l) Resident #81 Review of the RNP Flow Sheet for September 2010 revealed Resident #81 was to: "Ambulate /c rolling walker 150 ft min (minimum) contact guard assist... verbal cues to (symbol for increase) step length / stay inside walker." Restorative staff documented having provided this service on only four (4) of the first twenty (20) days of September (9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16), with four (4) refusals. - m) Resident #82 Review of the RNP Flow Sheet for September 2010 revealed Resident #82 was to have: "Active ROM - bilat lower ext - 3 sets 15 reps (seated marches, hip abduction / adduction, seated knee ext (extension)." Restorative staff documented having provided this service on only nine (9) of the first twenty (20) days of September (9/2, 9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). Also, she was to: "Ambulate /c rolling walker - contact guard assist of one to tolerance." Restorative staff documented having provided this service on only eight (8) of the first twenty (20) days in September (9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - n) During an interview with a restorative aide (Employee #58) on 09/20/10 at 5:45 p.m., she stated that restorative services were provided for each resident seven (7) days per week. She said there was one (1) restorative aide who worked from 10:00 a.m. to 6:00 p.m., and there were two (2) restorative aides who worked the 7:00 a.m. to 3:00 p.m. (7-3) shift. She said two (2) restorative aides were pulled to work the floor today, leaving the other restorative aide to obtain weights on thirty (30) residents and then work 1:1 with another resident. For this reason, the restorative aides did not perform restorative nursing services today to all residents who to receive services - other than restorative dining in the dining room for five (5) residents; a nurse would be at the restorative table for the evening meal. She said she did not perform range of motion exercises or assist with ambulating any restorative residents in the hall today. - o) During an interview with a nurse (Employee #43) on 09/21/10 at 2:00 p.m., regarding all the "blanks" in the Restorative Book where nothing was documented to show restorative services were done on those days, she said a new program went into effect the beginning of September whereby copies of the RNP Flow Sheets for residents and their specific treatments are placed in the NA's (nursing assistant's) ADL (Activities of Daily Living) book for NAs to sign on days they provide restorative nursing services. - p) During an interview with another nurse (Employee #101) on 09/21/10 at 2:10 p.m., she said the nursing assistants do the restorative care on the 7-3 shift if the restorative aides get pulled to work the floor. - q) During interviews on 09/21/10 at 2:20 p.m. with nursing assistants who provided care today or yesterday to the following residents (Employees #31, #94, and #59), the aides were asked what restorative nursing services they provided and answers were as follows: - For Resident #31 - "walked him to the bathroom and to the chair", "got range of motion to the upper and lower extremities today for a total of 10 minutes - restorative did it." - For Resident #63 - "was taken to the bathroom and transferred back and forth to the commode" - For Resident #6 - "transferred from the bed to the chair, moved arms and legs about 10 minutes" - For Resident #56 - "took her to the bathroom about ten times" - For Resident #23 - "helped during bathing" - For Resident #10 - "walked to the bathroom twice" - For Resident #17 - "worked arms and legs when changed" - For Resident #82 - "walked her to the bathroom and back" - For Resident #49 - "walked to the bathroom twice" - For Resident #70 - "walked to the bathroom to the hallway and to the chair" - For Resident #81 - "walked him to the bathroom" - For Resident #66 - "walked to the bathroom" - For Resident #92 - "had range of motion to the upper extremities today for 10 minutes - restorative did it." - r) During an interview with Employee #43 on 09/21/10 at 3:15 p.m., she said the process for the CNAs to provide restorative care when the restorative aides were not available just started the first of September. She stated that the CNAs, nurses, and physical therapy have all met with inservices given, and all the CNAs should know how to do restorative nursing services, but perhaps not all know how to do it correctly yet. When asked, she said she believed the restorative aide positions were here to stay, but she was certain. However, they want to empower the CNAs to be able to do restorative nursing care as part of their daily duties. - s) During an interview with the director of nursing (DON) on 09/21/10 at approximately 5:30 p.m. regarding what nursing assistants said they were providing to restorative residents on days the restorative aides were absent or pulled to the floor to work as CNAs, she said it was probably just the "verbiage" they were unfamiliar, with as they have all received inservice education on restorative care. - t) During interviews with eight (8) nursing assistants (Employees #31, #27, #54, #55, #59, #94, #112, and #108) on 09/22/10 from 10:00 a.m. to 11:45 a.m. seven (7) of the eight (8) replied, when asked, that they do ADLs with residents who are in the restorative program and do range of motion to their joints during the process of performing routine care, just as they do for all dependent residents. They were in agreement that, when they sign on the Restorative Nursing Flow Sheet, they are signifying that range of motion was completed during their shift plus getting them up in a chair and/or walking them to the toilet if they are able. They were in agreement that the restorative staff perform lengthy ambulation per the restorative plan, although they (the CNAs) will walk a resident in the hall if he/she asks; and it is the restorative staff that does specific exercises (such as seated marches, etc., and exercises with repetitions and sets), not the CNAs. One (1) of the eight (8) CNAs said she does the exercises and repetitions according to the Restorative Nursing Plan, but she said she was not sure what hip abduction / adduction entails. Also, she was unable to describe what PROM and AROM entails. - u) During an interview with the staff development nurse (Employee #104) on 09/22/10 at 12:15 p.m., she reported the facility conducted a CNA class that ended in July with twelve (12) graduates, and five (5) of them are currently working at the facility. Also, the current CNA class graduates on 09/23/10, with six (6) students in that class and they test on 10/09/10. She said the next class begins on 09/29/10 with ten (10) students. She spoke of her desire for the facility to be able to hire and retain more CNAs. - v) Prior to exit for the day on 09/22/10 at approximately 4:00 p.m., the DON was informed of the continued concern regarding whether residents in the restorative nursing program were getting services as specified in the restorative nursing program flow sheet on days the restorative aides were absent or were pulled to work the floor as CNAs (instead of restorative aides). No further evidence was produced prior to exit on 09/23/10. |
2014-01-01 |