State Findings:
During the initial part of the survey, interviews were conducted with residents and family regarding staffing. They stated staff takes 2-3 hours to answer their call light for assistance, that they have had to hold bowel/urine for 2 hours, waited an hour for requested medications, waited 2 hours for assistance from the wheelchair to the bed, requested a medication and the staff never came back, and that skin breakdown is the result of not getting the resident out of bed.
To ensure they have sufficient staff to meet the needs of the residents at any given time based upon the facility resident population and their needs for care and support revealed the PPD (hours per day per patient/resident) is typically at 0.24 for Registered Nurses (RN), the PPD is typically at 0.95 for Licensed Practical Nurses (LPN), and the PPD is typically around 1.80 to 1.95 for Certified Nursing Assistants (CNA).
An interview was conducted with an CNA (staff #58) on June 8, 2022 at 10:30 AM, who stated that
sometimes the facility is short-staffed. Staff #58 stated residents are supposed to receive showers two times a week and/or as needed but that when they are short staffed, she bathes as many residents as she can. She stated that when she does not have time to give a resident a shower, she will at least try to give the resident a bed bath to make them feel better. The CNA stated that she tries her best to make sure the residents receive good care, but that sometimes it is hard. She stated sometimes it takes a long time to pass out trays and some residents receive cold food.
An interview was conducted with the Staffing Coordinator (staff #3) on June 8, 2022 at 3:27 PM, Staff #3 stated their staff have been stretched thin so they have reached out to a staffing agency,
however it takes one to two weeks for the contract to be approved before staff can be scheduled. She stated the facility has had a high staff turnover. She also stated that last month was a big hiccup due to the contract ending with the staffing agency.
Review of the facility policy Nurse Scheduling and Timekeeping Process revised on April 1, 2016 revealed the facility will staff according to budget staffing levels and adjust schedules based on census.
Wound Care
Resident #238 was readmitted to the facility on 07/15/21 with diagnoses that included pneumonia, urinary tract infection, and mental disorder due to a known physiological condition.
The goal was for wound/skin impairment healing as evidenced by decrease in size, absence of erythema and drain age, and/or presence of granulation. Interventions included to turn and/or reposition and check skin every 2 hours as determined by tissue tolerance.
A Change in Condition Evaluation dated 12/13/21 revealed for a change in skin status described as an apparently minor recent wound which was now developing redness, swelling, or pain. The documentation noted 3 small open areas to the right gluteal fold.
A nursing note dated 12/17/21 indicated the resident had been evaluated and that treatment
had been provided by a nurse practitioner at the wound clinic. The note stated that the resident’s
orders had been updated and that continued monitoring and wound treatment would be
provided.
A nursing progress note dated 02/25/22 at 9:13 a.m. included for a change in condition due to
worsening of wound to the sacral area. The note stated that wound care had been completed and assessed by the wound nurse, the resident was frequently repositioned on a LAL mattress , and that the resident had an indwelling foley catheter placed with no adverse reactions noted.
On 06/08/22 at 1 :45 p.m. an interview was conducted with the Assistant Director of Nursing
(ADON/staff#19). She stated that the lapse in documentation from 12/23/22 through 01/28/22 was because the resident was probably not assessed or treated during that time. She stated that by 02/09/22 the resident’s wound was not MASO, and that by the time the resident was discharged the wound was probably infected, and maybe the resident was septic.
On 06/09/22 at 8:36 a.m. an interview was conducted with the Director of Nursing (DON/staff
#86). She stated that as she looked at the wound documentation for January 2022, it did
not meet her expectations. She said that nursing should have reached out to her to notify her of the
deterioration to the wound. She stated that in her estimation, the wound was active and should
have been identified before 01/29/22.
Your Experience Matters
...and we want to hear it.
NHAA is here to assist families, residents, and the community by sounding the alarm on issues like those found above. This nursing home and many others across the country are cited for abuse and neglect.
If you have or had a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.
We have helped many already and we can help you and your loved one as well by filing a state complaint, hiring a specialized nursing home attorney or helping you find a more suitable location for your loved one.
You can make a difference, even if your loved one has already passed away.
Please give us a call at 1-800-645-5262 or fill out our form detailing your experience.
Personal Note from NHA-Advocates
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If you are struggling and upset, click here to understand your options, or contact us through our contact form or call our toll free hot line number: 1-800-645-5262.
