cms_WV: 4045
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4045 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 353 | F | 0 | 1 | WA6611 | Based upon family interview, staff interview, review of staffing documentation, review of payroll information, review of incident reports, and review of reports documenting the provision of incontinence care for dependent residents, the facility failed to deploy sufficient qualified nursing staff across all shifts to provide nursing and related services and to ensure resident safety. These findings had the potential to affect all residents residing in the facility. Resident identifiers: #21, #26, #52, and #49 Facility census: 61. Findings include: a) During the survey, complaints regarding staffing were voiced on both of the facility's two (2) units, the second floor unit (Nursing Care Facility Two (NCF2)) and Nursing Care Facility One (NCF1). The units are completely separate. NCF2 currently houses primarily residents who need assistance or are totally dependent on nursing staff for their activities of daily living (ADLs). NCF1 currently houses primarily residents who are more mobile, require less staff assistance with ADLs, but may have dementia, mental illnesses, and behaviors. Because of the unique needs presented on each unit, they were investigated for adequate staffing separately. b) NCF2 1. Two (2) family members voiced concern about inadequate staffing on NCF2 during the early stages of the survey. Interviewee #1 said there were often staffing concerns on day shift. The individual thought there were supposed to be two (2) nurses and three (3) Nurse Aides (NA) on day shift, but usually there were only two (2) NAs, and sometimes only one N[NAME] Interviewee #1 said there were many times when their family member had to wait a long time for needed care, and as a result was sometimes left to sit or lie in their own excrement. Interviewee #1 said the staff tried their best, but they just could not do it with only four (4) staff, let alone with three (3). Lots of the residents needed assistance, some needed the assistance of two (2) staff, and when things got busy, lots of residents waited long time for help. Interviewee #2 also said most of the concern was with day shift. The individual said by early evening most of the residents were in bed, and staff was better able to attend to their needs. Interviewee #2 also said for the most part, the staff did their best to be attentive, but when there were only four (4) in total, or at times three (3), there was no way to meet everybody's needs consistently. 2. Staffing posting sheets and schedules were reviewed beginning on 02/15/17 at 9:30 a.m. The staffing postings, meant to inform residents and visitors of staffing levels throughout the day, rarely matched the schedules and assignments provided for the same day. Administrator #114 had said on 02/20/17 at 2:20 p.m. that almost none of the staffing postings were accurate. For this reason, Administrative Assistant #152 was asked to complete staffing worksheets from payroll records and to correlate that information with the postings and schedules to the extent possible. On 02/20/17 at approximately 2:30 p.m., Administrative Assistant #152 agreed the postings were not reliable. She compiled, and later provided, staffing worksheets that were correlated with payroll records to the extent possible. Administrative Assistant #152 said these records were the most accurate available and they were used for the investigation on both NCF2 and NCF1. Administrative Assistant #152 said sometimes when staffing was short on NCF2, staff were sent downstairs from the acute care hospital unit. This further complicated the ability to identify number of staff. If the staff from the third floor did not change their payroll code by clocking out on third floor and in to second floor, they would not be reflected in the payroll record as having worked on NCF2. The Administrative Assistant said she routinely reviewed the previous day's staffing to make needed corrections when staff from third floor covered NCF2 so her information would be as accurate as possible. Another complication identified was that some of the third floor NAs were registered long term care Nurse Aides and some were not. If third floor sent down a NA that was not registered, that NA could not be permitted to do actual resident care, but was limited to helping out by passing ice, setting up trays, making beds, and so forth. Another complication identified was that third floor staff were never sent to NCF1. When NCF1 needed help, third floor staff were sent to NCF2 and then existing NCF2 staff were sent to NCF1. This was not always able to be identified in the payroll system. 3. Review of the staffing levels on both NCF2 and NCF1 began on 02/21/17 at 8:30 a.m., and continued as days were added to the initial period requested from 01/29/17 to 02/11/17. The final period reviewed was from 01/29/17 to 02/21/17. For NCF2, the review found during that period, the highest day shift nursing staffing was 5.06. The lowest was 2.84. The average was 3.7. There were seven (7) days when the staffing was three (3) or less. There were seventeen (17) days when the staffing was four (4) or less. During those seventeen (17) days, non-certified aides who could not independently provide needed resident care were sent down to assist on 01/29/17, 01/31/17, 02/01/17, and 02/08/17. The census on NCF2 during the survey was twenty-two (22) residents. 4. Nurse #1 said there were usually two (2) nurses and two (2) NAs on NCF2 but not always. When asked if that staffing level was sufficient to meet the needs of the residents, Nurse #1 said, No. Nurse #1 said Look, at the situation here right now. We have twenty-two (22) residents, most need staff assistance for everything. There are two (2) nurses here, both doing medication pass. One NA is giving a bath, the other is transporting a resident downstairs. That leaves no one to answer call lights, provide incontinence care, or to respond to anything else in a timely manner. During an interview on NCF2, Nurse #2 also responded that staffing on NCF2 was not sufficient to meet the residents' needs. Nurse #2 said the nurses had to stop between passing needed medications and leave the medication cart to provide needed care to residents, which they were not supposed to do. Nurse #2 added that when non-certified aides came down from third floor, they really could not do much to help and had to be with a certified aide to even assist with actual care needs. Nurse #2 said sometimes when third floor sent staff to NCF2, NCF2 had to send one of their staff down to NCF1 because third floor staff did not want to go down there. 5. Nurse Aide (NA) #1 said the NAs could not do all the required care when there were only two. The NA said some of the nurses were good to help when needed, but some would not. NA #1 said there were times when he/she was the only NA on the floor, and also said sometimes they sent non-certified aides down to assist and they could not really do anything. 6. On 2/21/17 at 2:30 p.m., information was requested from the Minimum Data Set Assessment (MDS) Coordinator, RN #111 to show how many residents on NCF2 required assistance of, or were dependent, on two (2) or more staff for activities of daily living (ADLs). This information was provided and began to be reviewed on 02/22/17 at 8:56 a.m. The initial review found that of the twenty-two (22) current residents on NCF2: -- Five (5) residents either required the assistance of, or were totally dependent upon, two (2) or more staff for bathing. -- Six (6) either required the assistance of, or were totally dependent upon, two (2) or more staff for dressing. -- Eight (8) either required the assistance of, or were totally dependent upon, two (2) or more staff for toileting. -- Seven (7) either required the assistance of, or were totally dependent upon, two (2) or more staff for transferring, two (2) of which required the use of a mechanical lift and two (2) staff for transfers. When one (1) of these residents required assistance with just one of these ADLs, it would make two (2) caregivers unavailable for other residents during the time required to provide the needed care to the one (1) resident. 7. The ADL of incontinence care was chosen for a more detailed review. Nurse Aide (NA) documentation of when incontinence care was provided in (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) to date was requested for Residents #21 and #26 who were identified by the MDS Coordinator, RN #111 as needing assistance or being dependent for toileting. The facility's ADL documentation was maintained in the electronic medical record (EMR) and required the NAs to login to the medical records program, select their resident, and manually enter the information for each instance of providing incontinence care for each of their assigned residents for their entire shift. Residents #21 and Resident #26 were on a check and change schedule during rounds every two hours. The review found for the period from 12/01/16 to 02/27/17, there was virtually no evidence of toileting being provided every two (2) hours or as needed for either Resident #21 or #26. There were many occasions when no evidence was found that toileting had been done for four to even twenty-four hour intervals. For this reason, the reviews were shortened to include a sampling of some of the most egregious lapses on day shift through the sample period. 8. Resident #21 December (YEAR): -- On 12/03/16, there was no evidence of toileting from 10:52 a.m. to 8:39 p.m., around 9.5 hours. -- On 12/4/16, there was no evidence of toileting from 6:32 a.m. to 4:47 p.m., around 10 hours. -- On 12/7/16, there was no evidence of toileting from 12:21 p.m. to 11:49 p.m., around 11.0 hours. -- On 12/9/16, there was no evidence of toileting from 6:42 a.m. to 1:52 p.m., around 7 hours. -- On 12/10/16, there was no evidence of toileting from 1:56 p.m. to 11:36 p.m., around 9 hours. -- On 12/10/16, there was no evidence of toileting from 5:03 a.m. to 2:25 p.m., around 8.5 hours. -- On 12/12/16, there was no evidence of toileting from 1:28 p.m. to 11:14 p.m., around 10 hours. -- On 12/13/16, there was no evidence of toileting from 1:32 p.m. to 2:05 a.m. the following morning, around 13 hours. -- On 12/14/16, there was no evidence of toileting from 6:05 a.m. to 4:55 p.m., around 10 hours. -- On 12/18/16, there was no evidence of toileting from 7:37 a.m. to 6:53 p.m., around 11 hours. -- On 12/19/16, there was no evidence of toileting from 3:52 a.m. to 8:37 p.m., around 18 hours. -- On 12/3/16, there was no evidence of toileting from 10:52 a.m. to 8:39 p.m., around 9.5 hours. -- On 12/20/16, there was no evidence of toileting from 6:35 a.m. to 9:46 p.m., around 15 hours. -- On 12/21/16, there was no evidence of toileting from 4:00 a.m. to 4:20 a.m. the next day, around 24 hours. -- On 124/3/16, there was no evidence of toileting from 2:06 p.m. to 1:00 a.m. the next day, around 11 hours. -- On 12/26/16, there was no evidence of toileting from 6:57 a.m. to 2:03 p.m., around 7 hours. -- On 12/28/16, there was no evidence of toileting from 3:03 p.m. to 2:25 p.m. the next day, around 23 hours. -- On 12/30/16, there was no evidence of toileting from 11:19 a.m. to 11:01 p.m., around 11 hours. January (YEAR): -- On 01/02/17, there was no evidence of toileting from 7:04 a.m. to 2:25 p.m., around 7.5 hours. -- On 01/03/17, there was no evidence of toileting from 2:25 p.m. the previous day to 10:18 p.m., around 20 hours. -- On 01/06/17, there was no evidence of toileting from 6:57 a.m. to 11:41 p.m., around 17 hours. -- On 01/08/17, there was no evidence of toileting from 6:25 a.m. to 1:21 p.m., and again until 11:42 p.m., the first being around 7 hours, and the second around 10 hours. -- On 01/10/17, there was no evidence of toileting from 10:45 a.m. to 10:00 p.m., around 11 hours. -- On 01/11/17, there was no evidence of toileting from 11:10 a.m. to 1:12 p.m. the next day, around 14 hours. -- On 01/13/17, there was no evidence of toileting from 7:01 a.m. to 3:00 a.m. the next day, around 20 hours. -- On 01/16/17, there was only evidence of toileting at 7:05 a.m. to 1:13 a.m. the next day, around 17 hours. -- On 01/19/17, there was no evidence of toileting from 10:57 p.m. the night before to 2:04 p.m., around 15 hours, and again until 11:50 p.m., around 10 hours. -- On 01/21/17, there was no evidence of toileting from 10:51 p.m. the night before to 2:36 p.m., around 15 hours. -- On 01/22/17, there was no evidence of toileting from 6:23 a.m. to 4:22 p.m., around 10 hours. -- On 01/24/17 and 1/25/17, there was no evidence of toileting from 10:38 a.m. on 1/22 until 9:20 a.m. on 1/23, around 23 hours. -- On 01/27/17, there was no evidence of toileting from 4:09 a.m. to 10:27 p.m., around 18 hours. -- On 01/29/17, there was no evidence of toileting from 6:04 a.m. to 10:59 p.m., around 16 hours. February (YEAR): -- On 02/6/17, there was no evidence of toileting from 6:55 a.m. to 7:32 p.m., around 12 hours. -- On 02/8/17, there was no evidence of toileting from 6:38 a.m. to 10:42 p.m., around 17 hours. -- On 02/9/17, there was no evidence of toileting from 2:19 a.m. to 12:19 a.m. the next night, around 22 hours. -- On 02/11/17, there was no evidence of toileting from 6:48 a.m. to 7:54 p.m., around 12 hours. -- On 02/14/17, there was no evidence of toileting from 7:01 a.m. to 3:28 a.m. the next day, around 20 hours, and again until 3:42 a.m. the next day, around 24 hours. -- On 02/22/17, there was no evidence of toileting from 7:11 a.m. to 3:14 p.m., around 8 hours. -- On 2/26/17, there was no evidence of toileting from 2:30 a.m. to 11:11 a.m., around 8 hours. 9. Resident #26 This resident received Hospice services. She had a care plan that said the Hospice nursing assistant would visit and provide personal care and baths 2 days weekly on Monday and Wednesday. Care would include complete bath/shower with hair care, skin care, mouth care and peri care. To eliminate any doubt regarding toileting, Mondays and Wednesdays were not included in the review. December (YEAR): -- On 12/01/16, there was no evidence of toileting from 6:21 a.m. to 10:54 p.m., around 17 hours. -- On 12/04/16, there was no evidence of toileting from 6:40 a.m. to 2:04 p.m., around 7 hours. -- On 12/10/16, there was no evidence of toileting from 3:05 p.m. to 10:01 p.m., around 7 hours. -- On 12/13/16, there was no evidence of toileting from 1:31 p.m. to 10:45 p.m., around 9 hours. -- On 12/16/16, there was no evidence of toileting from 7:40 a.m. to 1:55 p.m., around 6 hours. -- On 12/17/16, there was no evidence of toileting from 6:28 a.m. to 9:13 p.m., around 16 hours. -- On 12/18/16, there was no evidence of toileting from 7:36 a.m. to 7:51 p.m., around 11 hours. -- On 12/20/16, there was no evidence of toileting from 6:33 a.m. to 9:52 p.m., around 15 hours. -- On 12/23/16, there was no evidence of toileting from 3:02 a.m. to 2:59 p.m., around 12 hours. -- On 12/24/16, there was no evidence of toileting from 2:43 a.m. to 2:50 p.m., around 12 hours. -- On 12/25/16, there was no evidence of toileting from 6:37 a.m. to 2:27 a.m. the next day, around 19 hours. -- On 12/27/16, there was no evidence of toileting from 6:25 a.m. to 10:27 p.m., around 14 hours. -- On 12/30/16, there was no evidence of toileting from 7:00 a.m. to 7:09 a.m. the next day, around 24 hours. January (YEAR): -- On 01/03/17, there was no evidence of toileting from 6:33 a.m. until 1:19 a.m. the next day, around 19 hours. -- On 01/07/17, there was no evidence of toileting from 6:53 a.m. to 11:52 p.m., around 17 hours. -- On 01/08/17, toileting was only documented once, at 7:53 p.m. This would have been around 20 hours from the night before. -- On 01/10/17, there was no evidence of toileting from 6:26 a.m. to 9:17 p.m., around 17 hours. -- On 01/12/17, there was no evidence of toileting from 6:18 a.m. to 10:39 p.m., around 16 hours. -- On 01/13/17, there was no evidence of toileting from 6:55 a.m. to 10:21 p.m., around 16 hours. -- On 01/17/17, there was no evidence of toileting from 10:00 a.m. to 7:46 p.m., around 10 hours. -- On 01/19/17, there was no evidence of toileting from 1:24 a.m. to 2:14 p.m., over 12 hours, and then until 2:00 a.m. the next day, about 12 hours. -- On 01/22/17, there was no evidence of toileting from 6:30 a.m. to 12:03 a.m. the next day, around 17 hours. -- On 01/26/17, there was no evidence of toileting from 11:28 p.m. the night before to 2:26 p.m., around 15 hours. -- On 01/27/17, there was no evidence of toileting from 7:03 a.m. to 10:32 p.m., around 15 hours. -- On 01/28/17, there was no evidence of toileting from 6:28 a.m. to 5:20 p.m., around 11 hours. -- On 01/29/17, there was no evidence of toileting from 6:02 a.m. to 10:56 p.m., around 17 hours. -- On 01/31/17, there was no evidence of toileting from 6:45 a.m. to 11:48 p.m., around 17 hours. February (YEAR): There was no evidence of toileting documented from -- 6:58 a.m. on 02/03/17 until 11:08 a.m. on 02/04/17, around 16 hours. -- On 02/05/17, there was no evidence of toileting from 6:26 a.m. to 3:42 p.m., around 9 hours. -- On 02/09/17, there was no evidence of toileting from 6:51 a.m. to 3:05 p.m., around 8 hours. -- On 02/10/17, there was no evidence of toileting from 6:53 a.m. to 8:43 p.m., around 13 hours. -- On 02/11/17, there was no evidence of toileting from 7:44 a.m. to 9:44 p.m., around 14 hours. -- On 02/15/17, there was no evidence of toileting from 6:52 a.m. to 9:07 p.m., around 14 hours. -- On 02/19/17, there was no evidence of toileting from 6:48 a.m. to 9:58 p.m., around 15 hours. -- On 02/24/17, there was no evidence of toileting from 4:20 a.m. to 2:51 p.m., around 10 hours 10. When asked about the lack of evidence that toileting and peri-care was provided, NA #1 said part of the problem was the cumbersome system the NAs had to use to enter the documentation. All the NAs had varying levels of computer skills. Some could navigate through the steps fairly well, and some just could not do it. This had been brought to the attention of nursing and administration many times, but nothing ever changed. NA #1 said they carried a scrap of paper around with them to jot down when they did the care for each of their residents, which could be 11 or 12 or even more on NCF2 day shift. Then at the end of the shift you have to stay over and try to get all that put in the computer. NA #1 said there had been times when they worked 16 hour shifts on two different units, meaning they would have to then stay over and try to enter documentation on care provided to up to 30 or more residents after working 16 hours straight. NA #1 said for the NA's, it often simply came down to a decision whether to provide needed care or do documentation. The NA said although some care was being provided but not documented, all the needed care was just not consistently getting done. c) NCF1 1. Family Member #3 said their family member tells them they have to wait a long time for care. 2. Review of staffing posting sheets and schedules beginning on 02/15/17 at 9:30 a.m., found the postings, meant to inform residents and visitors of staffing levels throughout the day, rarely matched up with the schedules and assignments provided for the same day. Administrator #114 had said on 02/20/17 at 2:20 p.m. that almost none of the staffing postings were accurate. Administrative Assistant #152 was asked to complete staffing worksheets from payroll records and to correlate that information with the postings and schedules to the extent possible. On 02/20/17 at approximately 2:30 p.m., Administrative Assistant #152 agreed the postings were not reliable, and compiled and provided staffing worksheets that had been correlated to payroll records to the extent possible. Administrative Assistant #152 said these records were the most accurate available and they were used for the investigation on both NCF2 and NCF1. Another complication identified was that third floor staff were never sent to NCF1. When NCF1 needed help, third floor staff were sent to NCF2 and then existing NCF2 staff were sent to NCF1. This was not always able to be identified in the payroll system. 3. Review of the staffing levels on both NCF2 and NCF1 began on 02/21/17 at 8:30 a.m., and continued as days were added to the initial period requested from 01/29/17 to 02/11/17. The final period reviewed was from 01/29/17 to 02/21/17. For NCF1, the review found during that period, the highest evening shift nursing staffing was 8.18. The lowest was 3.5. The average was 5.76. There were five (5) days when the staffing was five (5) or less. The highest night shift staffing was 4.03. The lowest was 2.62. The average was 2.91. There were eighteen (18) days when the staffing was less than three (3). The census on NCF1 during the survey was thirty-nine (39) residents. 4. Nurse #1, initially interviewed on NCF2, said after 7:00 p.m. there were often two (2) aides and one (1) nurse on NCF1. Nurse #1 said with that staffing there was no way to keep track of what was going on. Nurse #2, initially interviewed on NCF2, also responded that after 7:00 p.m. there were often two (2) aides and one (1) nurse on NCF1. Nurse #2 said on NCF1, They (the residents) are all still up at night. The nurse said the residents, .are falling, trying to elope, and wandering into other residents' room and doing things they should not be doing. Observations on 02/22/17 at 8:00 p.m. found the staff posting listed 1 nurse and 4 NAs until 11:00 p.m. Nurse #3 stated there was always one nurse on nights and if there was a problem, you had to prioritize. Nurse #3 said, Bleeding and chest pain comes first. It was acknowledged that after 11:00 p.m., there were 2 NAs scheduled on NCF1. 5. In an interview, NAs #3 and #4 said the staff that night was 1 nurse and 4 NAs until 11:00 p.m. and after 11:00 p.m., there would be 1 nurse and 2 NAs. On the short hall there were five (5) residents who required 2 person assist and on the long hall there were 10 residents who needed two (2) person assist, even though there was only one Hoyer lift on the long hall, the other residents just could not be done with one person. They said there was not enough staff to safely take care of the residents, because, We only have enough time to change them. The aides said they were unable to turn the resident's every two hours or to spend quality time with any of the residents and monitor them. 6. On 02/27/17 at 11:57 a.m., review of incident reports for NCF1 for 01/01/17 to 02/08/17 found for evening and night shift on NCF1 during those 39 days there had been 17 residents found on the floor after apparent falls which staff were not present to observe. There were 3 observed falls. There were 4 altercations or behavior related incidents. In addition to these 24 documented incidents, the survey team discovered and cited as an immediate jeopardy due to 8 incidents of sexual abuse by male residents on NCF1. The action pledged by the facility to abate the immediate jeopardy was the immediate deployment of 3 additional NAs or Nurses to monitor the male residents to adequately protect the other residents. 7. On 02/21/17 at 2:30 p.m., information was requested from the Minimum Data Set Assessment (MDS) Coordinator, RN #111 to show how many residents on NCF1 required assistance of, or were dependent on, two (2) or more staff for activities of daily living (ADLs). This information was provided and a review begun on 02/22/17 at 8:56 a.m. The initial review found that of the 39 residents on the floor: -- 3 residents were totally dependent on 2 or more staff for dressing, -- 5 residents required either assist of, or were dependent upon, 2 or more staff for toileting, and -- 5 residents required either assistance of, or were dependent upon, 2 or more staff for transfers. Of those 5 residents, 4 required a mechanical lift with assist of 2 or more staff for transfers. 8. The ADL of incontinence care was chosen for a more detailed review. Nurse Aide documentation of when incontinence care was provided in (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) to date was requested for Residents #21 and #26 who were identified by the MDS Coordinator, RN #111 as needing assistance or being dependent for toileting. The facility's ADL documentation was maintained in the electronic medical record (EMR) and required the nurse aides to login to the medical records program, select their resident, and manually enter the information for each instance of providing incontinence care for each of their assigned residents for their entire shift. Residents #51 and Resident #49 were on a check and change schedule during rounds every two hours. The review found for the period from 12/1/16 to 2/27/17, there was virtually no evidence of toileting being provided every two hours or as needed for either resident #51 or #49. There were many occasions when no evidence was found that toileting had been done for four to even twenty-four hour intervals. For this reason, the reviews were shortened to include a sampling of some of the most egregious lapses on day shift through the sample period. 9. Resident #51 This resident's care plan included that a Hospice nursing assistant would visit and provide personal care and baths 2 days weekly on Tuesday and Thursday. Care would include a complete bath/shower with hair care, skin care, mouth care and peri care. To eliminate any doubt regarding toileting, Tuesdays and Thursdays were not included in the review. December (YEAR): -- On 12/03/16, there was no evidence of toileting from 6:04 a.m. to 12:23 a.m. the next night, around 14 hours. -- On 12/04/16, there was no evidence of toileting from 6:30 a.m. to 8:19 p.m., around 18 hours. -- On 12/08/16, there was no evidence of toileting from 2:45 a.m. to 10:54 p.m., around 20 hours. -- On 12/11/16, there was no evidence of toileting from 3:15 a.m. to 2:34 p.m., around 11 hours. -- On 12/12/16, there was no evidence of toileting from 2:00 a.m. to 8:42 p.m., around 18 hours. -- On 12/16/16, there was no evidence of toileting from 6:00 a.m. to 3:25 p.m., around 8 hours. -- On 12/17/16, there was no evidence of toileting from 6:20 a.m. until 1:44 a.m. the next day, around 19 hours. -- On 12/18/16, there was no evidence of toileting from 11:41 a.m. to 2:26 a.m. the next day, around 15 hours. -- On 12/21/16, there was no evidence of toileting from 2:42 a.m. to 10:05 p.m., around 19 hours. -- On 12/30/16, there was no evidence of toileting from 10:22 a.m. to 10:24 p.m., around 12 hours. January (YEAR): -- On 01/04/17, there was no evidence of toileting from 6:00 a.m. to 9:21 p.m., around 15 hours. -- On 01/09/17, there was no evidence of toileting from 8:27 a.m. to 6:22 p.m., around 10 hours. -- On 01/10/17, there was no evidence of toileting from 2:53 a.m. to 1:15 p.m., around 10 hours. -- On 01/15/17, there was no evidence of toileting from 1:00 p.m. to 8:50 p.m., around 8 hours. -- On 01/16/17, there was no evidence of toileting from 6:43 a.m. to 7:05 p.m., around 12 hours. -- On 01/18/17, there was no evidence of toileting from 7:45 a.m. to 12:02 a.m. the next day, around 16 hours. -- On 01/22/17, there was no evidence of toileting from 4:52 a.m. to 2:20 p.m., around 10 hours. -- On 01/25/17, there was no evidence of toileting from 6:00 a.m. to 2:34 p.m., around 8.5 hours. -- On 01/30/17, there was no evidence of toileting from 7:45 a.m. to 7:30 p.m., around 12 hours. February (YEAR): -- On 02/01/17, there was no evidence of toileting from 6:42 a.m. to 8:50 p.m., around 13 hours. -- On 02/17/17, there was no evidence of toileting from 6:30 a.m. to 2:02 p.m., around 7.5 hours. -- On 02/21/17, there was no evidence of toileting from 6:30 a.m. to 2:30 p.m., around 8 hours. -- On 02/22/17, there was no evidence of toileting from 4:32 a.m. to 6:25 p.m., around 14 hours. 10. Resident #49: December (YEAR): -- On 12/13/16, there was no evidence of toileting from 4:26 a.m. to 5:00 p.m., about 12.5 hours. -- On 12/17/16, there was no evidence of toileting from 10:14 a.m. to 9:01 p.m., about 11 hours. -- On 12/18/16, there was no evidence of toileting from 6:04 a.m. to 2:02 p.m., about 8 hours. -- On 12/20/16, there was no evidence of toileting from 7:17 a.m. to 3:30 p.m., about 8 hours. -- On 12/25/16, there was no evidence of toileting from 2:00 a.m. to 8:19 p.m., about 13 hours. -- On 12/28/16, there was no evidence of toileting from 6:26 a.m. to 8:19 p.m., about 9 hours. -- On 12/31/16, there was no evidence of toileting from 2:30 a.m. to 10:33 p.m., about 20 hours. January (YEAR): -- On 01/03/17, there was no evidence of toileting from 6:16 a.m. to 2:30 p.m., about 8 hours. -- On 01/04/17, there was no evidence of toileting from 6:43 a.m. to 3:00 p.m., about 8 hours. -- On 01/07/17, there was no evidence of toileting from 7:27 a.m. to 4:30 p.m., about 9 hours. -- On 01/12/17, there was no evidence of toileting from 6:33 a.m. to 7:43 p.m., about 13 hours. -- On 01/03/17, there was no evidence of toileting from 6:16 a.m. to 2:30 p.m., about 8 hours. -- On 01/15/17, there was no evidence of toileting from 7:40 a.m. to 12:44 a.m. the next day, about 17 hours. -- On 01/18/17, there was no evidence of toileting from 7:15 a.m. to 7:08 p.m., about 12 hours. -- On 01/21/17, there was no evidence of toileting from 7:22 a.m. to 8:26 p.m., about 13 hours. -- On 01/22/17, there was no evidence of toileting from 6:51 a.m. to 6:24 p.m., about 12 hours. -- On 01/23/17, there was no evidence of toileting from 4:37 a.m. to 2:29 p.m., about 7 hours. February (YEAR): -- On 02/01/17, there was no evidence of toileting from 5:26 a.m. to 2:42 p.m., about 8 hours. -- On 02/08/17, there was no evidence of toileting from 6:46 a.m. to 4:30 p.m., about 9 hours. -- On 02/12/17, there was no evidence of toileting from 6:54 a.m. to 2:08 p.m., about 7 hours. -- On 02/13/17, there was no evidence of toileting from 2:30 a.m. to 1:45 p.m., about 11 hours. -- On 02/15/17, there was no evidence of toileting from 6:45 a.m. to 4:53 p.m., about 10 hours. -- On 02/20/17, there was no evidence of toileting from 5:53 a.m. to 8:34 p.m., about 14 hours. -- On 02/24/17, there was no evidence of toileting from 9:48 a.m. to 8:00 p.m., about 10 hours. -- On 02/25/17, there was no evidence of toileting from 2:29 p.m. to 11:06 p.m., about 8.5 hours. 11. When asked about the lack of evidence to support that adequate toileting and peri care was being provided, NA #2 described the cumbersome time consuming process the NAs were required to use to document their care. The NA said some NAs were able to get some of the documentation recorded and some were not. NA #2 said even though the difficulty in documenting was a big problem, the care was simply not getting done consistently due to inadequate staffing of NAs on NCF1. 12. Although some of the lack of evidence of care being given might be due in part to limitations of the aides' ability to keep up with the system they are required to utilize for documentation, it was found that on NCF1, the facility reported and substantiated an allegation of neglect on 09/10/16. The 09/10/16 incident substantiated by the facility was that Resident #51 was left in a recliner chair from 5:33 a.m. until 5:30 p.m. During that time, she received no food, no hydration, and was not toileted or repositioned. | 2020-02-01 |