| 6933 |
RIVER OAKS |
515120 |
100 PARKWAY DRIVE |
CLARKSBURG |
WV |
26301 |
2014-10-16 |
353 |
F |
1 |
0 |
TXTJ11 |
Based upon record review, review of staffing postings, staffing assignment sheets, nursing schedules, payroll records, assessed care needs, staff interviews, family interviews, and resident interviews, the facility failed to consistently ensure sufficient nursing staff across all shifts to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. This deficient practice had the potential to affect all residents living in the facility. Facility census: 88. Findings include: a) Complaints received by the Office of Health Facility Licensure and Certification (OHFLAC) led to an on site investigation into allegations, including allegations of insufficient staff to provide needed care during some shifts in August, September, and October 2014. These complaints received by OHFLAC identified some specific shifts when staffing was alleged to be insufficient, and review of the facility's complaint files and abuse/neglect reporting files on 10/06/14 at 9:30 a.m., found additional complaints and allegations related to staffing, delays in care, and neglect. Resident, family, and staff interviews during the investigation of these concerns resulted in additional staffing concerns and other specific dates when insufficient staffing was alleged. The following were sampled for detailed investigation: 1) It was alleged on the 08/29/14 day shift, there were only four (4) nursing assistants working in the facility to care for 87 residents. 2) It was alleged on the 09/08/14 day shift, there were only four (4) nursing assistants working in the facility to care for 86 residents. 3) It was alleged on the 10/03/14 night shift, there was only one (1) nursing assistant working in the facility on the Jackson Court wing to care for 42 of the facility's 89 residents. 4) It was alleged on the 10/03/14 night shift there were only two (2) aides working in the facility on the Nutter Fort Court side of the facility to care for 47 of the facility's 89 residents. 5) It was alleged on the 10/11/14 afternoon shift, there were no aides scheduled to work on the Nutter Fort Court side of the facility to care for 49 of the facility's 88 residents. b) Review of staff posting sheets, staffing assignment sheets, nursing schedules, and payroll records confirmed staffing levels were low on some of the shifts identified for a sampled detailed investigation. This review also found there were discrepancies between the postings, staffing sheets, schedules, and actual payroll data. Detail for each date was as follows: 1) Staffing for 08/29/14 08/29/14 day shift: A complaint being investigated reported there were only four (4) nursing assistants in the building on the 7:00 a.m. - 3:00 p.m. day shift Friday, August 29th, the staffing was not posted for the complainant to see, and toileting, meal tray delivery, and response to call lights were not done in a timely manner. A review of the staffing posting furnished by the facility showed nine (9) nursing assistants had originally been documented for the day shift, but this had been lined out and replaced at some point with 5.5 nursing assistants. It was also noted the posting documented there were only two (2) nursing assistants on the night shift. The census was documented as 87. Two (2) different staffing assignment sheets were provided for 08/29/14. The sheets started with the same typed list of scheduled nursing assistants, including both facility employees and outside agency nursing assistants which showed seven (7) aides scheduled to work the entire shift and two (2) scheduled to come in at 11:00 a.m. Both sheets were marked with lines and notes indicating call-offs, time changes, adjustments in assignments, and a note on one of them that mandating had been refused. The two (2) sheets showed completely different arrangements to attempt to cover the schedule. It was noted that both assignment sheets documented only two (2) nursing assistants were working on the 11:00 p.m. - 7:00 a.m. night shift. Payroll records were requested for 08/29/14. They verified one (1) agency aide was paid for working from 7:00 a.m. to 3:00 p.m. on that shift. Another agency aide was paid for working 7:00 a.m. - 2:00 p.m. on that shift, a facility-employed aide was paid for working 10:00 a.m. - 3:00 p.m. on that shift, and a facility-employed aide was paid for working 7:08 a.m. - 3:00 p.m. on that shift. This established there had actually been slightly less than four (4) nursing assistants working the day shift on 08/29/14. The payroll data for night shift verified one (1) facility-employed nursing assistant was paid for working from 11:00 p.m. - 7:00 a.m. on that shift on the Jackson Court side, and another facility-employed aide was paid for working 11:00 p.m. - 7:00 a.m. on the Nutter Fort Court side of the building. 2) Staffing for 09/08/14 09/08/14 day shift: A complaint being investigated reported there were only four (4) nursing assistants in the building on the 7:00 a.m. - 3:00 p.m. day shift Monday, September 8th. A review of the staffing posting furnished by the facility showed eight and a half (8.5) nursing assistants had been documented for the day shift. The census was documented as 86. Three (3) different staffing assignment sheets were provided for 09/08/14. The sheets started with the same typed list of scheduled nursing assistants, including both facility employees and outside agency nursing assistants which showed eight (8) aides scheduled to work the entire shift. All three (3) sheets were marked with lines and notes indicating call-offs, time changes, and adjustments in assignments. Payroll records were requested for 09/08/14. They verified one (1) agency aide was paid for working from 7:00 a.m. to 3:00 p.m. on that shift, another agency aide was paid for working 7:00 a.m. - 3:00 p.m. on that shift, a facility-employed aide was paid for working 7:00 a.m. - 3:00 p.m. on that shift, and a facility-employed aide was paid for working 7:00 a.m. - 3:00 p.m. on that shift. This established there had actually been four (4) nursing assistants working the day shift on 09/08/14. The payroll data for day shift also included hours for two (2) nurses. Their hours on day shift for 09/08/14 were originally coded as follows: A registered nurse's hours covering the entire day shift were originally coded as registered nurse hours. These had been adjusted from the registered nurse account and moved to the nursing assistant account on 10/13/14, the day the request for the payroll data was made. A licensed practical nurse's hours covering the entire day shift were originally coded as licensed practical nurse hours. These had been adjusted from the licensed practical nurse account and moved to the nursing assistant account on 10/13/14, the day the request for the payroll data was made. The staffing assignment sheets listed two (2) other nurses scheduled for both Jackson Court and for Nutter Fort Court. On 10/16/14 at 9:40 a.m., one of the complainants was asked if they were told licensed nurses were working the floor as aides to help cover the assignments for day shift. The complainant said they asked how many aides were working and they were told there were only four (4) aides working. They were not told any nurses were called in to assist with the needed care on the floor. 3) 10/03/14 10/03/14 night shift: Facility complaint files and abuse/neglect reporting documented a resident on the Nutter Fort Court side of the building complained about not being assisted to get out of bed before the day shift began on the early morning of 10/03/14. The facility documented this as a complaint, and also reported it, not as an allegation of neglect for not accommodating the resident's request to be gotten up, but as an allegation of verbal abuse because a nursing assistant allegedly told him they only had two (2) aides for forty-seven (47) residents and did not have time to get him up. Residents #65, #69, and #85 were interviewed multiple days and times throughout the survey, the last times being on 10/15/14 at 1:34 p.m. (Resident #65), 1:47 p.m. (Resident #69), and 2:00 p.m. (Resident #85). They all said there was only one (1) nursing assistant on the Jackson Court side of the facility during night shift on 10/03/14, and there was another night about a month ago when the same aide had worked alone all night. Residents #65 and #69 said one of the nurses was trying to assist the aide with care needs, answering call lights, etc., but this put her behind in providing her nurses' care duties A review of the staffing posting furnished by the facility showed three (3) nursing assistants had been documented for the night shift. The census was documented as 87. Two (2) different staffing assignment sheets were provided for 10/03/14. The sheets both showed for night shift there were two (2) aides assigned to Nutter Fort Court and one (1) aide assigned to Jackson Court. Payroll records were requested for 10/03/14. They verified a facility-employed aide was paid for working 11:00 p.m. - 7:00 a.m. on that shift, and two (2) facility-employed aides were paid for working 11:00 p.m. - 7:00 a.m. on that shift. 4) 10/11/14 10/11/14 afternoon shift: During the survey, some facility staff provided a staffing assignment sheet which indicated no nursing assistants were assigned to work the 3:00 p.m. to 11:00 p.m. shift on the Nutter Fort Court side of the building on Saturday, October 11th. A review of the nursing schedule found no nursing assistants had even been scheduled for the shift. A visit was made to the facility on the afternoon of Saturday, October 11th at 3:35 p.m. Upon arrival, a nursing assistant on the Nutter Fort Court was asked how many aides were working at that time. She said the facility had called her and asked if she could come in. Even though she had worked several extended shifts in a row, she had agreed to come in from 3:00 p.m. until 7:00 p.m. In addition to her, there was a housekeeper, who maintained a valid nursing assistant registration who had agreed to work the shift as an aide. Two (2) licensed practical nurses said they had volunteered to work as aides for the shift. Payroll data was requested for 10/11/14. It verified one facility-employed nursing assistant worked from 3:00 p.m. - 6:57 p.m. during the shift, one (1) licensed practical nurse worked from 3:00 p.m. - 7:00 p.m. on the shift, one (1) licensed practical nurse worked from 3:00 p.m. - 7:34 p.m. on the shift, and one (1) licensed practical nurse worked from 7:00 p.m. - 11:00 p.m. on the shift as a float aide. The housekeeper's hours were not furnished, but she confirmed she was working as an aide with an assignment, she does possess a current registration, and it was reasonable to credit those hours as having been worked to cover the shift. Staff were asked if the scheduling of licensed nurses to work as aides was a common method of providing need coverage. They said it was not customarily done. One (1) staff member said if the surveyor had not been in the facility since 10/06/14 looking at staffing, none of the additional staff would have been there today. c) Review of residents' care needs as assessed by the facility and continuing interviews with residents and staff confirmed that due to a variety of challenges with staff turnover, retention, and availability for deployment, there were shifts when there was not sufficient nursing staff to provide needed care to residents. Pertinent findings included: 1) Residents' care needs, complaints, and accidents:Review of the Resident Census and Condition of Residents report (CMS-672) completed by the facility upon entrance found there were: -- fifteen (15) residents who were totally dependent upon two (2) or more staff for transfers with a mechanical lift. Ten (10) residents were on Nutter Fort Court and five (5) were on Jackson Court. -- There were also fifty-one (51) residents listed as requiring assistance of one (1) to two (2) staff for transfers. -- Thirty-eight (38) residents were totally dependent on staff for bathing. Twenty-four (24) were on Nutter Fort Court and fourteen (14) were on Jackson Court. -- There were also forty-six (46) residents listed as requiring assistance of one (1) or two (2) staff for bathing. -- Eight (8) residents were totally dependent for toileting. Seven (7) were on Nutter Fort Court and one (1) was on Jackson Court. -- There were also seventy (70) residents listed as requiring the assistance of one (1) or two (2) staff for toileting.Review of shower schedules for 10/13/14 - 10/18/14 found for Nutter Fort Court an average of ten (10) showers on day shift and seven (7) on evening shift. For Jackson Court, there was an average of seven (7) showers on day shift and five (5) on afternoon shift. Based upon these documented care needs provided by the facility, it would not be possible to provide all needed care to residents requiring assistance of one (1) or two (2), and those who were totally dependent, in a timely manner as well as answer call lights, monitor assigned residents and perform all the other duties of a nursing assistant with two (2) nursing assistants on a wing for day shift or afternoon shift, and with one (1) nursing assistant on a wing during the night shift.Review found there were twenty-five (25) documented complaints in the last three (3) months regarding staffing, call light response, or delays in care and treatment. There were sixty-one (61) unwitnessed falls during the last three (3) months. 2) Resident and family interviews: Interviews were conducted throughout the survey. Two (2) family members requested confidentiality stating they were concerned about what would happen should the facility learn what they had to say. A family member interviewed on 10/08/14 at 11:35 a.m. said he/she was concerned there was not sufficient staff to monitor residents who were at risk for falls. His/her loved one had suffered multiple falls which were not witnessed. He/she said his/her loved one often had to wait a long time for help, especially with toileting, and he/she thought that may be the reason for some falls, when the residents tried to get up and go to the bathroom on their own.A family member was interviewed on 10/14/14 at 11:40 a.m. The family member said he/she was concerned about his/her loved one falling because there was not enough staff to check on the residents as much as they should. He/she said staffing was bad, especially on weekends and he/she felt it was affecting resident care and safety. Resident #65 was determined by her physician to possess the capacity to make informed medical decisions on 09/22/12. Her Brief Interview for Mental Status (BIMS) score as assessed on 7/23/14 was 15, which would indicate she was cognitively intact. She was interviewed multiple times during the survey, the last time being on 10/15/14 at 1:34 p.m. She lived on the Jackson Court wing. She said staffing was a big problem, especially on nights and weekends. She often had to wait a long time for assistance, and she was not able to transfer and do a lot of other things for herself. She felt she was being neglected.Resident #69 was determined by the facility as interviewable. Her Brief Interview for Mental Status (BIMS) score as assessed on 08/12/14 was 15, which would indicate she was cognitively intact. She was interviewed multiple times throughout the survey, the last time being on 10/15/14 at 1:47. She lived on the Jackson Court wing. She said many evenings and nights call lights went unanswered and care was done late if it was done at all. She said there have been a couple of nights in the last month when there was only one (1) nursing assistant trying to take care of the entire wing. She said just recently one (1) of the nurses was trying to help the aide answer lights and assist with needed care, but she got behind in her own work by doing it. She said her roommate fell on a Friday night and no one came to help her for a long time, and she was not able to help due to her own dependence on staff for transfers and other care needs. Resident #85 was determined by her physician to possess the capacity to make informed medical decisions and acted as her own responsible party. Her Brief Interview for Mental Status (BIMS) score as assessed on 08/29/14 was 15, which indicated she was cognitively intact. She was interviewed multiple times during the survey, the last time being 10/05/14 at 2:00 p.m. She lived on the Jackson court wing. She also said there had recently been two (2) occasions when there was only one (1) nursing assistant to care for the entire wing at night. She said there had been times when there were only two (2) nursing assistants on the wing for day shift and evening shift, and there was just no way they could do it. She said the same staff had to work over and cover absences all the time, and they got tired and even got sick. She said staff were leaving because they were tired of the staffing problems. She said when surveyors were in the building they did everything they could to make sure there was enough staff, but once they left, it was just the same as it was before.Resident #30 was determined by her physician to possess the capacity to make informed medical decisions on 02/23/14. Her Brief Interview for Mental Status (BIMS) score as assessed on 09/16/14 was 14, which indicated she was cognitively intact. She was interviewed on 10/15/14 at 2:42 p.m. She lived on the Nutter Fort Court wing of the facility. She had made a complaint, which resulted in an immediate reporting of an allegation of neglect, which was completed, on 07/17/14. Resident #30 said she had rung her call bell for assistance to be toileted, but no one came and she ended up completely soaked. The investigation concluded the allegation could not be substantiated, but did note that the documentation on the night shift did not reflect that the care had actually been provided. The nursing assistant was subsequently disciplined for not documenting they had provided the care. The resident said it was no better now than it was then. She often had to wait for help until she had been incontinent. She said she complains, but they do not do anything. She said they just do not make sure there are enough people working. Not just nights or weekends, although they were the worst, but even day shift through the week sometimes they were very short. She said its not just call-offs; They just don't schedule enough people. 3) Direct care staff interviews:Nursing assistants #1, #2, and #3 were interviewed between 5:30 a.m. and 7:00 a.m. on 10/08/14. They said there were often times when there were only two (2) aides on a wing on night shift. There have been times when there was only one (1). They did not feel there was any way the residents could receive the care they need with staffing at those levels.Nursing assistant (NA) #4 was interviewed on 10/08/14 at 1:40 p.m. The NA said he/she work mostly 3:00 p.m. - 11:00 p.m. shift, but often come in early or stay late and work twelve (12) hours. He/she said he/she had worked twelve (12) to sixteen (16) hours for eight (8) or nine (9) days in a row and still got called on his/her day off to come in to cover for low staffing. The same people were mandated to stay over and over again. Those aides got tired; they even got dehydrated and got sick. Some have had to go to the hospital. He/she said when you have been here five (5) years you can refuse to be mandated to stay and cover for missing staff, so the newer staff had to do it all the time. There were only just a few nurses that would try to help with things when the staffing was low. The newer aides were all quitting because they were fed up.NA #5 was interviewed on 10/09/14 at 3:07 p.m. The NA said he/she had been mandated for seven (7) to eight (8) days straight. He/she said last weekend even with mandating there were only two (2) aides for at least part of the evening shift. Even the kitchen staff and the housekeepers tried to help with passing trays and answering call lights. They said there were only a few agency-nursing assistants available now, while there used to be a lot of them. They said they would no longer come to the facility because of the way they were treated. NA #6 was interviewed on 10/09/14 at 3:58 p.m. The NA said there were many times when there were only two (2) aides on a wing during evening shift. The NA said, Its not so much call-offs; they just don't schedule enough staff. He/she said the weekends were the worst. Most nurses would not help, and when there were eight (8) to ten (10) showers to be done with two (2) aides, the care just could not be done. The NA also said agency staff would not come any more because of the workload and the treatment. He/she said, When surveyors are here there are plenty of staff and plenty of snacks and when you leave they don't care.NA #7 was interviewed on 10/13/14 at 5:32 a.m. The NA said he/she had been the only aide on Jackson Court a couple of times in the past month. He/she said one of the nurses tried to help with the care.NAs #8 and #9 were interviewed on 10/13/14 at 6:00 a.m. They said when there were allegations of neglect, and care had not been documented in the computer by the aide, the facility said the allegations were not substantiated because the care was provided and then disciplined the aide for not putting it in the computer that care was done. They said when nurses try to call management on-call, they never get any help from them. They either do not answer or refuse to come in and help.Licensed Nurse #1 was interviewed on 10/08/14 at 3:38 p.m. The nurse said the only thing he/she could say was, They need to staff this place better.Licensed Nurse #2 was interviewed on 10/14/14 at 2:42 p.m. The nurse said there have certainly been days when there was just not enough staff to provide basic care. He/she said staffing with nurses working as aides as had been done just recently does not routinely happen. Some nurses tried to help, but then their medications and treatments would get late. The nurse said they can get no help from management. They do not even bother to call any more, they just do the best they can.Licensed Nurse #3 was interviewed on 10/14/14 at 3:03 p.m. The nurse said he/she had been called to come in on night shift over the weekend and when he/she got to the facility, was told he/she would be working as an aide. The nurse said there had been two (2) Friday nights recently when there was just one aide and the nurses on the wing. He/she said nurses had never been assigned to work as aides to cover shifts until the surveyors showed up.Licensed nurse #4 was interviewed on 10/14/14 at 4:00 p.m. The nurse said he/she always tried to help with the care on the floor when nursing assistant staffing was very low. He/she said many aides have left to work at the newly opened mental health facility in the area, and that had caused difficulty in covering the schedule consistently.4) Management and support staff interviews:The staffing and scheduling coordinator was interviewed on 10/07/14 at 12:42 p.m. She was asked about the staffing assignment sheets, schedules, and staff posting sheets, and why there were sometimes multiple copies with different numbers, names, and hours entered. She said in the current situation it was very confusing and hard to reconcile. The staffing assignments sheets and the schedule were often changed many times, even right up to the beginning of a shift. There were some shifts that started off with few or even no one scheduled and got filled in as best as possible by the time the shift started. She said there had been a high turnover and lots of call-offs. The same people tended to stay over to cover multiple shifts and they got tired.The human resources director was initially interviewed on 10/13/14 at 1:00 p.m. There was a discussion of staffing issues and challenges. She provided information over the next two (2) days showing some of the concerns and efforts being made to address them. She said turnover in the nursing department was a big concern. She provided staff turnover statistics covering 01/01/14 to the present that showed the following: -- Twenty-seven (27) nursing assistants had been hired and thirty-five (35) had resigned or been terminated. -- Five (5) registered nurses had been hired and five (5) had resigned or been terminated. -- Four (4) licensed practical nurses had been hired and eight (8) had resigned or been terminated.She provided a listing of currently available contracted agency nursing assistants, which included six (6) nursing assistants from two (2) staffing agencies. The listing of available contracted nursing assistants from November 2013 included thirty-five (35) nursing assistants from three (3) staffing agencies.She was asked about current procedures for mandating aides to stay over at the end of their shift to cover the next shifts. She said nursing assistants employed by the facility for five (5) years or more could not be made to stay past their scheduled quitting time unless they did so voluntarily. Therefore, nursing assistants who were more recently hired were mandated to stay when staffing levels could not be maintained on the incoming shifts.She was asked about the statement noted on some of the staffing assignment sheets that said Do not pull aides unless 2 call-offs. Can pull agency. She clarified the current procedure was that nursing assistants could not be moved from Jackson Court wing to Nutter Fort wing or vice versa to balance the deployment of available staff unless there had been two (2) call-offs on the wing. If there were two (2) aide positions not covered because there were none available or none scheduled, the assignments may not be balanced between the wings. This had resulted in situations as found on night shift when there could be three (3) aides on one wing and only one (1) on the other.She provided information about a newly established recruitment and retention committee charged with creating and implementing a recruitment and retention plan of action. The composition of the committee was to include shorter and longer service employees, with representatives from each shift and department, and at least 50% should be level one employees. Some of the activities for October 2014 directly related to staffing were to contact area high schools, tech centers, and colleges to set up face to face meetings, implementation of sign on bonuses for nursing assistants and nurses, review of old applications with follow up contacts to let them know about current opportunities, help wanted ads to run in newspapers and on Craigslist, and various staff recognition efforts.She was asked about the on-call schedule for registered nurses. She said there was a rotation among the registered nurses so they would know when they were assigned to be available for call in case of emergencies or staffing problems. She was asked to provide that current schedule. This document was not provided as of the time of the exit conference. Information was also requested for any previous instances of licensed nurses working as aides, with their own assignment as verified by payroll data, as opposed to trying to help out, but still retaining full responsibility for the nurses' duties on the shift. No further payroll information was provided to demonstrate any other past practice of utilizing nurses in this mannerThe administrator was interviewed on 10/14/14 at 9:47 a.m. Findings concerning staffing issues were discussed. It was explained to her that doing a detailed review of payroll data for every shift of every day for the past three (3) months was not feasible, and a sample of dates and shifts had been chosen from concerns identified through complaints and interviews. She was asked about the registered nurses on-call schedule. She said with the turnover in registered nurses and the current vacancies, the acting/interim director of nursing had been the only on call registered nurse for some time, going back to late August or September 2014. She was aware there had been occasions when she was not always available to take call. She was asked if any earlier documented instances had been found when licensed nurses were scheduled to work exclusively as aides to cover critical shortages. She said there had been none except those already documented and discussed. She agreed maintaining adequate staff had been challenging in the last few months. She said there had been attempts to cover that were successful and some instances when they were not. She said two (2) nursing assistants on a wing for day shift or evening shift, or one (1) nursing assistant on a wing at night was not enough to get the job done. |
2017-10-01 |