cms_WV: 18
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 18 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 353 | E | 1 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, visitor interview, staff interview, medical record review, observation, and policy review, the facility failed to ensure sufficient staff to implement resident care plans and respond to residents' needs for thirty-four (34) of thirty-four (34) residents reviewed for restorative services (#101, #104, #105, #107, #112, #116, #121, #124, #125, #150, #153, #16, #160, #187, #192, #195, #2, #20, #21, #26, #31, #37, #4, #45, #47, #49, #5, #59, #61, #64, #7, #76, #82, and #141) and twelve (12) residents (#93, #125, #34, #43, #103, #126, #41, #121, #22, 104, 189, and #93) observed during the dining experience. Facility census: 116. Findings include: a) Resident #76 Medical record review found a minimum data set (MDS) with an assessment reference date (ARD) of 05/09/17 that identified Resident #76 required the extensive assistance of one (1) person for bed mobility. The MDS indicated the resident had impairment on both sides of his upper and lower extremities. The resident received hospice services for end of life care related to end stage [MEDICAL CONDITIONS]. Nurse Aide (NA) #135, interviewed on 05/23/17, verbalized Resident #76 had gotten weak and now staff did more for him than he did for himself. She said he was not eating at all. Licensed Practical Nurse (LPN) #62 concurred the resident had a recent decline. A Stage 1 observation on 05/15/17 at 2:14 p.m. found Resident #76 leaning to the right side without support to maintain an upright position. On 05/23/17 at 9:12 a.m., the resident was in bed lying on his back with the head of the bed elevated to about 45 degrees. The resident had slid down in bed. At 2:44 p.m., an observation revealed Resident #76 slid down in bed and was eating lunch. An unidentified NA was feeding the roommate and his brother and sister-in-law were standing at the bedside. Licensed Practical Nurse (LPN) #62 observed the resident and confirmed he was not positioned correctly and needed pulled up in bed. She asked the NA to assist her to position him correctly to eat his meal. b) Resident #141 During a Stage 1 interview on 05/16/17 at 2:57 p.m., Resident #141 verbalized he was supposed to receive restorative therapy for ambulation, but had not received it for three (3) weeks. The resident voiced a concern that he lost strength and endurance when he did not walk with restorative. review of the resident's medical record revealed [REDACTED]. Additionally, the physician's orders [REDACTED]. During an observation and interview with Resident #141 on 05/23/17 at 9:15 a.m. the resident said he had his bath and was waiting for the nurse to provide his pain relief therapy. He verbalized restorative would walk him after that. At 12:28 p.m., the resident said, No one has walked me yet. and at 2:30 p.m., the resident said he had not yet walked. The resident said he had walked three (3) times the previous week, but had not walked at all the three (3) weeks prior to that. Resident #141 expressed he felt like he was losing his strength. Another observation at 5:53 p.m. revealed the resident sleeping bed. Nurse Aide (NA) #37, interviewed at 12:48 p.m. on 05/23/17, said Resident #141 walked with restorative aides, but they get pulled to the floor a lot so it doesn't (does not) get done. The NA said the resident had no routine, just slept most of the day. The NA voiced the resident did not usually refuse to walk, but it took him a while because his legs shake. The NA reported it took about forty-five (45) minutes to an hour to walk him from his room to the doorway of the conference room and back, and that he usually took a break. The NA verbalized the resident walked on a good week four (4) times. During an interview with Nurse Aide (NA) #23 on 05/24/17 at 2:36 p.m., the NA reviewed the restorative records and said Resident #141 was supposed to walk 150 feet two (2) times a day. The NA verbalized restorative noted the shift and time of resident participation and/or refusal and if no entry was present, then restorative did not ask the resident to ambulate. Upon request, the NA reviewed the (MONTH) (YEAR) and (MONTH) (YEAR) activity participation log and confirmed no evidence was present to indicate services had been offered on the dates of 05/01/17, 05/02/17, 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/13/17, 05/14/17, 05/15/17, 05/16/17, 05/19/17, 05/21/17, 05/22/17, and 05/23/17. Additionally, no evidence was present to indicate it was offered twice on the dates of 05/17/17, 05/18/17, 05/20/17, and 05/24/17. The log noted Resident #141 had refused on the 3-11 shift on 05/03/17, 05/04/17 and 05/08/17, with no evidence it was offered during the 7-3 shift. The (MONTH) (YEAR) log indicated Resident #141 did not receive restorative ambulation services for the dates of 04/07/17, 04/09/17, 04/10/17, 04/13/17, 04/14/17, 04/15/17, 04/16/17, 04/18/17, 04/19/17, 04/21/17, 04/22/17, 04/25/17, 04/27/17 04/29/17, or 04/30/17. Additionally, NA #23 confirmed no evidence was present to indicate ambulation services had been offered twice daily on 04/08/17, 4/17/17, 04/23/17, and 04/28/17. The resident was out of facility for one (1) date and refused for four (4) of twenty-three (23) opportunities. The interim Center Nurse Executive (CNE), interviewed on 05/24/17 at about 3:00 p.m., confirmed Resident #141 had not received restorative services as per the plan of care. c) Resident #27 Medical record review related to accidents revealed a physician's orders [REDACTED].#27 required the limited assistance of one (1) person for ambulation, and utilized a walker and/or wheelchair. The assessment noted the resident was not steady, but able to stabilize without staff assistance. [DIAGNOSES REDACTED]. Further review of the medical record revealed a physician's orders [REDACTED]. - nursing to assist resident to ambulate 80 feet two (2) times a day with roll walker and gait belt using CGA (contact guard assist) six (6) days a week. Re-evaluate in 90 days and as needed. -Restorative nursing to assist with bilateral lower extremity (BLE) exercises using two pound (2 lb) weight-hip flexion, knee extension three (3) sets times ten (10) repetitions daily six (6) days a week. Re-evaluate in 90 days and as needed. The care plan indicated Resident #27 was at risk for falls and risk for bleeding related to anticoagulant therapy. It noted the resident demonstrated a deficit in ambulation related to (r/t) functional deterioration resolved on 04/01/17 and revised on 04/20/17. During an observation and interview with Resident #27 on 05/31/17 at 4:32 p.m., the resident voiced she stayed in her room most of the time, but walked to the bathroom. Upon inquiry, the visitor said she was at the facility about three (3) times a week, and was adamant Resident #27 had not been walking in the hallway with restorative nursing. Restorative Nursing records, reviewed for the period from 05/01/17 through 05/24/17 indicated Resident #27 only walked one (1) time a day on the days she received restorative ambulation. Additionally, no evidence was present to indicate the resident received restorative as ordered from 05/10/17 through 05/24/17. No data was entered for the dates of 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, or 05/23/17. Review of the restorative nursing documentation for bilateral lower extremity exercises yielded no data for 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, and 05/23/17. Nurse Aide (NA) #37, interviewed on 05/23/17 at 12:48 p.m., verbalized only the restorative nurse aides walked with Resident#27 in the hallway for restorative care. NA #23, interviewed on 05/24/17 at 2:36 p.m., verified the residents did not receive restorative therapy if no data was present. The restorative/rehabilitative nursing program plan indicated the skilled functional area deficit was required because a potential for decline existed and to maintain the current level of function. Program instructions indicated therapy be completed six (6) days a week. The interim center nurse executive (CNE), interviewed on 05/24/17 at 3:30 p.m., confirmed restorative care had not been provided as directed by the plan of care. d) Residents #101, #104, #105, #107, #112, #116, #121, #124, #125, #150, #153, #16, #160, #187, #192, #195, #2, #20, #21, #26, #31, #37, #4, #45, #47, #49, #5, #59, #61, #64, #7, and #82. A complaint investigation was conducted simultaneously with a Quality Indicator Survey from 05/15/15 through 06/02/17 related to staffing concerns and a failure to provide care and services. During an interview with Nurse Aide (NA) #23 on 05/24/17 at 2:36 p.m., the NA reviewed the restorative records and verbalized restorative noted the shift and time of resident participation and/or refusal. The NA said if no entry was present then restorative did not ask the resident to participate. The restorative nursing record, reviewed for the dates of 05/01/17 through 05/14/17 indicated residents received nursing services per physician's orders [REDACTED].#141 and #27, as follows: - Resident #125: Restorative Nursing to assist resident to perform bilateral upper extremity active range of motion/passive range of motion (AROM/PROM) in all planes ten (10) repetitions (reps) for three (3) sets daily six (6) days a week. Re-evaluate in 90 days. Review of the (MONTH) (YEAR) restorative nursing record indicated Resident #125 did not receive restorative services for 12 of 20 opportunities. - Resident #116: Restorative Nursing to provide right upper extremity (RUE) AROM/PROM: fingers, wrist, and elbow- flexion extension, Right (R)-shoulder flexion ten (10) reps times three (3) sets daily as tolerated six (6) days a week. Re-evaluate on 06/22/17 and as needed (PRN). Also, restorative nursing to provide transfer training from w/c (wheelchair) to chair and chair to w/c four (4) times a day with gait belt and minimal assist six (6) times a week. Chair and w/c to be placed ten (10) feet apart. Re-evaluate on 07/09/17. The restorative nursing record indicated the resident did not receive restorative services for 12 of 24 opportunities: 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/16/17, 05/17/17, 05/18/17, 05/19/17, 05/21/17 and 05/22/17. - Resident #45: Restorative staff to assist Resident to ambulate 100 feet two (2) times a day with roll walker, gait belt, and minimal assist with wheel chair (w/c) to follow per resident's tolerance six (6) days a week. Re-evaluate program on 07/09/17 and prn. No evidence was present to indicate the resident received services for fourteen (14) of 24 opportunities. - Resident #107: Restorative nursing to assist resident to perform left lower extremity (LLE) exercises - seated marches and long arc quads ten (10 sets times three (3) reps six (6) days a week, initiated on 04/13/17. Restorative nursing to assist Resident to perform five (5) sit-to-stand transitions using hallway rail outside of room with minimal assist and gait belt to stand up and contact guard assist (CGA) while standing (six 6) days a week. Re-evaluate in 90 days and as needed. No evidence was present to indicate services were offered for six (6) of twelve (12) opportunities. Restorative nursing to perform right upper extremity (RUE) PROM in all planes for ten (10) repetitions for two (2) sets daily as tolerated six (6) days a week and re-evaluate on 07/04/17 and PRN. Restorative staff to apply RUE hand roll splint following PROM for up to four (4) hours a day six (6) days a week. Inspect skin prior to application and after removal of hand splint. Re-evaluate on 07/04/17 and as needed. Restorative nursing to assist resident perform right lower extremity (RLE) PROM in all planes flexion/extension, and abduction/adduction. Ten (10) reps times two (2) sets daily as tolerated six (6) days a week. No evidence was present to indicate the resident received services as ordered between 05/06/17 and 05/24/17. - Resident #192 - Restorative nursing to assist resident perform LLE (left lower extremity) exercises while supine in bed - straight leg raises, heel slides, quad sets, abduction/adduction .three (3) reps times ten (10) sets daily six (6) days a week. Re-evaluate on 07/09/17 and PRN. Restorative nursing to assist resident to perform LUE (left upper extremity) exercises with stress ball .three (3) reps times ten (10) daily six (6) times a week. No evidence was present to indicate the facility provided services six (6) times a week including the dates of 05/02/17, 05/05/17, 05/06/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/18/17, 05/19/17, 05/21/17, 05/22/17, 05/23/17, and 05/24/17. - Resident #5: Restorative dining - resident to attend restorative dining six (6) days a week, lunch meal to increase nutritional intake. Revaluate on 06/10/17 and PRN. The restorative nursing record indicated restorative dining was not provided as ordered. Restorative nursing to assist with BLE (both lower extremities) therapeutic exercises while sitting .three (3) sets times ten (10) reps six (6) days a week. No evidence was present to indicate service were offered for the dates of 05/06/17, 05/09/17, 05/10/17, 05/11/17, 05/18/17, 05/19/17, 05/21/17 and 05/22/17. Additionally, the form indicated Resident #5 had refused on 05/03/17, 05/04/17, 05/16/17, and 05/17/17. - Resident #112: Restorative nursing to assist resident to ambulate 40 feet two (2) times with roll walker, CGA and w/c to follow six (6) days per week. Restorative nursing to assist resident to stand five (5) times daily for three (3) minutes each stand with CGA six (6) days per week. No evidence was present to indicate the facility attempted ambulation for the dates of 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/18/17, 05/19/17, 05/21/17, 05/22/17 or 05/24/17. - Resident #64: Restorative nursing to assist resident perform UE (upper extremity) exercises using yellow theraband .for ten (10) reps times two (2) sets daily six (6) days a week. No evidence of participation/refusal was noted for the dates of 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17 05/18/17, 05/19/17, 05/21/17 or 05/22/17. - Resident #121: Restorative nursing to assist with RUE active assistive range of motion (AAROM) .three (3) sets times ten (10) reps as tolerated by resident six (6) days a week. The resident refused on four (4) occasions with an additional thirteen (13) opportunities. Restorative to ambulate resident 150 feet twice daily .six (6) days a week. Omissions of opportunity included 05/02/17, 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/18/17, 05/19/17, 05/21/17, 05/22/17, and 05/23/17. Additionally, no evidence was present to indicate services were offered twice daily as ordered for 24 of 24 opportunities. - Resident #16: Restorative nursing to provide LUE PROM in all planes one time a day Restorative staff to apply left resting hand splint following PROM - . Re-evaluate on 06/10/17. No evidence was present to indicate the splint was applied as ordered for or offered for the dates of 05/06/17, 05/09/17, 05/10/17, 05/11/17, 05/16/17, 05/17/17, 05/18/17, 05/19/17, 05/21/17, or 05/22/17. - Resident #195: Restorative nursing to ambulate resident one (1) time daily 100 feet with roll-walker and CGA six (6) days a week, initiated on 05/13/17. Restorative nursing to transfer resident from bed to w/c or w/c to armchair with ten (10) feet separation between objects four (4) times a day .six (6) times a week. Review in 90 days. Restorative records indicated services were not offered/provided as ordered. - Resident #160: Restorative nursing to assist resident perform LUE PROM .re-evaluate on 07/23/17 and PRN. Restorative to apply LUE posey hand roll following PROM six (6) days a week. Restorative records indicated services were not provided per physician's orders [REDACTED]. - Resident #2: Restorative nursing to assist with BLE therapeutic exercises while sitting .using three (3) pound weights three (3) sets times ten (10) reps six (6) days a week - re-evaluate on 07/03/17. Restorative nursing to assist with trunk flexion .five (5) times a day six (6)days a week. Re-evaluate on 7/03/17 and PRN. The restorative nursing record was silent to services on 05/02/17, 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/18/17, 05/19/17, 05/21/17, 05/23/17 and 05/24/17. - Resident #101: Restorative nursing to assist with BUE home theraband exercise program using yellow theraband .six (6) days a week. Re-evaluate on 07/19/17 and PRN; Restorative nursing to assist with BLE exercises .six (6) days a week. The restorative nursing record indicated the resident did not receive services as ordered. - Resident #104: Restorative nursing to provide gentle PROM to head/neck .then position with memory foam pillow Restorative nurse to provide BLE AAROM . six (6) times a week. Restorative to provide BUE PROM in all planes .six 96) times a week to prep for splinting of bilateral UE. Restorative nursing to apply BUE regular posey finger contracture rolls following PROM .six (6) days a week. Re-evaluate on 07/09/17 and PRN. No evidence was present to indicate the service was provided and/or offered on 05/06/17, 05/09/17, 05/10/17, 05/18/17, 05/19/17, or 05/21/17. - Resident #82: Restorative nursing to apply left resting hand splint following LUE PROM .six (6) days a week. Restorative nursing to assist with BLE therapeutic exercises .six (6) days a week Restorative records indicated services were not provided six (6) days a week. - Resident #105: Restorative staff to assist resident to stand 3 reps daily using roll walker and perform weight shifting up to one (1) minute then stand high marches for up to one (1) minute six (6) days a week. Restorative staff to assist resident to ambulate 50 feet to 300 feet daily with roll walker .assist with w/c to follow .six (6) days a week. Re-evaluate on 07/04/17. The restorative nursing record indicated services were not offered or provided as ordered for 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/15/17, 05/16/17, 05/17/17, 05/18/17, 05/19/17, and 05/21/17. - Resident #21: Restorative nursing to assist Resident perform five (5) sit-to-stand .six (6) days a week Restorative nursing to assist with BLE exercises while sedated .six (6) days per week. The restorative records indicated services were not provided and/or offered on 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/18/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, 05/23/7 or 05/24/17. The resident refused services on 05/03/17, 05/04/17, 05/16/17 and 05/17/17. - Resident #31: Restorative nursing to assist with BLE therapeutic exercises .six (6) days a week. Re-evaluate on 05/15/17. Restorative nursing to assist with BUE therapeutic theraband home exercise program .six (6) days a week. Re-evaluate on 05/15/17. No evidence was present to indicate services were provided and/or offered on the dates of 05/05/17, 05/06/17, 05/07/17, 05/08/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/21/17, 05/23/17, or 05/24/17. - Resident #20: Restorative nursing to assist resident to perform BUE AROM .six (6) days a week. The restorative nursing log indicated staff did not offer/provide services on 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/21/17, or 05/23/17. Restorative nursing to assist BLE PROM .daily six (6) days a week, and Restorative nursing to apply lower extremity wedge for up to four (4) hours per day .six (6) days a week. Re-evaluate in 90 days. The log revealed no services were offered on 05/06/17, 05/08/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17 05/14/17, 05/18/17, 05/19/17, 05/21/17 or 05/23/17. - Resident #47: Restorative nursing to provide BLE - ankles AAROM .six (6) days a week, and Restorative nursing to provide BUE AAROM ROM .six (6) days a week . Re-evaluate on 06/10/17 and PRN. The restorative log indicated the facility did not offer restorative services on 05/06/17, 05/08/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, and 05/21/17. - Resident #153: Restorative nursing to assist resident to ambulate from room to Rehab Dining room, and then back to room .six (6) days a week Restorative dining: Resident to attend restorative dining six (6) days a week, lunch meal to increase safety and efficiency of swallowing function The restorative nursing records indicated restorative dining services were not provided as ordered, between 05/01/17 and 05/13/17. - Resident #61: Restorative staff to assist resident to ambulate from room to dining room and back daily with roll walker .six (6) days a week. Restorative nursing to provide transfer training from w/c to chair or chair to w/c with ten (10) feet separation .six (6) days a week. The restorative nursing record was silent for dates of 05/06/17, 05/08/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, or 05/21/17. - Resident #7: Restorative nursing to assist resident perform BLE PROM .six (6) times a week Restorative nursing to assist resident perform BUE exercises using five (5) pound weight and red theraband .six (6) days a week, re-evaluate in 90 days. The restorative log indicated services were not provided six (6) days a week or offered and/or provided for thirteen (13) opportunities between 05/01/17 and 05/24/17. - Resident #4: Restorative dining lunch meal six (6) times a week .re-evaluate on 06/10/17. The log indicated services were not provided as ordered between 05/01/17 and 05/10/17. - Resident #150: Restorative to ambulate Resident 50-100 feet one (1) time daily .imitated on 05/05/17 - re-evaluate in 90 days and prn. The restorative record was silent for the dates of 05/06/17, 05/07/17, 05/08/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/15/17, 05/16/17, 05/19/17, 05/20/17, 05/21/17, and 05/24/17. - Resident #26: Restorative nursing to provide BUE PROM in all planes .six (6) days a week; Restorative nursing to provide BLE PROM in all planes . re-evaluate in 90 days and PRN. The record indicated no services offered on 05/01/17, 05/02/17, 05/06/17, 05/09/17, 05/10/17, 05/12/17, 05/14/17, 05/16/17, 05/17/17, 05/18/17, 05/19/17, 05/20/17, or 05/21/17. - Resident #49: Restorative to ambulate resident two (2) times daily 50 feet with hemi-walker and CGA six (6) days a week, initiated on 05/13/17. The restorative log indicated the facility failed to offer services for eight (8) of twelve (12) days and for twenty (20) of thirty two opportunities. Restorative nursing to transfer resident from bed to w/c or w/c to armchair .six (6) times a week. Restorative was not offered for eight (8) of 12 opportunities. - Resident 124: Resident to attend restorative dining six (6) times a week, lunch meal The restorative log indicated the order was not completed as ordered from 05/01/13 through 05/24/17. - Resident #187: Restorative staff to assist resident to ambulate 150 feet twice a day with roll walker .six (6) days a week Restorative nursing to provide transfer training from w/c to chair .six (6) times a week. Services were not provided for thirteen (13) opportunities. e) Daily Staffing and Assignment sheets for 04/16/17 to 05/24/17, reviewed on 05/24/17 at 10:45 a.m., indicated restorative nursing was transferred from restorative services to nurse aide assignment services for all or part of a day on 05/19/17, 05/18/17, 05/17/17, 05/16/17, 05/08/17, 05/07/17, 05/04/17, 05/03/17, 05/02/17, 04/30/17, 04/28/17 (late), 04/27/17, 04/25/17, 04/24/17, 04/21/17, 04/19/17 04/18/17, 04/16/17. The assignment sheets also indicated only one (1) NA was assigned and/or performed restorative services on 05/24/17, 05/23/17, 05/22/17, 05/19/17, 05/21/17, 05/19/17, 05/17/17, 05/16/17, 05/15/17, 05/14/17, 05/12/17, 05/09/17, 05/08/17, 05/06/17, 05/05/17, 05/04/17, 05/03/17, 05/02/17, 04/30/17, 04/28/17, 04/23/17, 04/22/17, 04/21/17, 04/17/17, and 04/16/17. f) The interim Center Nurse Executive (CNE) interviewed on 05/24/17 at about 3:00 p.m., confirmed residents had not received restorative services as per physician's orders [REDACTED]. New orders, dated 05/25/17 to 05/26/17 to discontinue and/or reduce restorative services to four (4) days a week included 27 of 27 residents reviewed: Resident #27, #61, #26, #150, #49, #141, #187, #195, #160, #101, #105, #21, #31, #20, #47, #153, #61, #125, #45, #107, #192, #5, #112, #84, #121, and #16. The administrator, at 6:40 p.m. on 06/01/17, requested to share the facility's quality assurance action plan. The administrator verbalized a staffing concern had been identified on 03/24/17 and a plan initiated that date to address concerns related to restorative services. The administrator said the facility was reviewing the services monthly to determine if the plan was working and if not, would revise it again. The administrator said that on 05/25/17 the program was reviewed and revised to reduce restorative care to four (4) days a week, as that was manageable for the facility and what residents were routinely receiving and required. g) Residents #93, #125, #34, #43, #103, #126, #41, #121, and #22 The dining schedule indicated lunch meals were served to areas as follows: fine dining 11:25 a.m. rehab (restorative) 11:30 a.m. south hall 12:10 p.m. south hall 12:15 p.m. east hall 12:20 p.m. east hall 12:30 p.m. north hall 12:35 p.m. north hall 12:40 During a random observation, on 06/01/2017 12:50 p.m., an overhead page announced, Lunch is now being served on east hall. Within a few minutes the food cart was delivered and parked by entrance near the main dining room. The time was 30 minutes later than noted on the schedule for the first cart. At 12:55 p.m.,on 06/01/17, observation of the South Hall revealed staff passing trays from the food cart on the hallway. NA #34 informed Resident #93 and #125 they would be helped soon. Upon inquiry, the NA said ten (10) residents required assistance with meals and two (2) nurse aides were passing trays. The dining schedule indicated the meal trays would be served at 12:10 p.m. - At 12:58 p.m., NA #2 passed a tray to Resident #34 and began to feed her. - At 12:58 p.m., Registered Nurse (RN) #126 and the interim CNE said they would assist. The CNE passed a tray to Resident #93 and fed her. - At 1:02 p.m. RN #126 passed a tray to Resident #125 - At 1:07 p.m., RN #108 passed a tray to Resident #121 - At 1:10 p.m. Resident #41 was asleep, her meal tray on the table in front of her. A small fly/gnat was crawling on her sandwich. The resident had not eaten her meal. - Resident #64 was asleep with her tray uneaten - At 1:14 p.m. Resident #22 had not eaten. At this time NA #34 entered the room and encouraged the resident to eat. - At 1:15 p.m., NA #103 tried to awaken Resident #43, but the resident was not responding. NA #2 talked loudly to the resident and rubbed her chest in circular motions with his hand. The resident barely opened her eyes for a second and went back to sleep. - At 1:19 p.m. LPN #94 walked by the room of Resident #41 and #103, but did not stop or try to awaken the residents who had not started eating their meals. h) Residents #104, #189, and #63 Observation of the North Hall meal tray service at 1:20 p.m., revealed staff passing meal trays - At 1:26 p.m. meal tray served to Resident #104 who was fed by NA #41. - At 1:27 p.m. - trays passed to Resident #189 and #63 by Health Information Management Coordinator (HIMC) #50 During an interview with Resident #92 on 05/16/17 at 10:28 a.m., the resident voiced meal services were often late 30 to 60 minutes. i) During an interview with the interim CNE, on 06/01/17 at about 2:15 p.m., an inquiry was made as to who the facility addressed staffing concerns. The CNE verbalized the restorative nursing staff was pulled to the floor. She further added that staff in other disciplines, who were also nurse aides, were sometimes pulled to the floor. Additionally, the CNE verbalized staff from sister facilities would help. With inquiry as to how staff functions during the evening meals and on weekends when administrative staff is not in the facility to assist, the CNE verbalized the weekend manager assisted. Discussion included that four (4) administrative staff assisted on two (2) hallways during the lunch meal observation on 06/01/17. | 2020-09-01 |