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F0725
D

Insufficient Staffing Affects Resident Activities and Dining

Everett, Pennsylvania Survey Completed on 01-15-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient nursing staff to meet the needs of residents, specifically in transporting them to activities and ensuring a licensed nurse was present in the main dining area during lunch and dinner. A grievance from a resident indicated that they were unable to attend activities due to the unavailability of nursing aides for transportation. Observations and interviews revealed that residents preferred to eat in the dining room but were not aware it was open, and they experienced long wait times for a nurse, leading them to eat in their rooms instead. Staff interviews confirmed that it was easier to serve residents in their rooms due to staffing constraints. The dietary delivery schedule showed specific times for meal deliveries, but the dining room was underutilized, with only one resident present during lunch. Interviews with nurse aides and the dietary manager confirmed that residents were not using the dining room due to staffing issues, as nurse aides were too busy with daily care tasks and lacked assistance from activity aides who had been let go. The Director of Nursing was unaware of the reasons behind the dining room's underuse and confirmed that residents should have been transported to activities by nurse aides.

Plan Of Correction

1. Facility unable to fix retroactively. Dining room times to be displayed along with daily meals outside of dining room. 2. Audits to be completed for each hall to obtain which residents would like to attend the dining room for meals. Dining services to be updated on current resident preference of meal location. 3. All staff will be educated on resident rights and dining room times. 4. Audit of dining room attendance will be completed 5x per week x2 weeks then weekly x 4. ED/Scheduler will review schedules 5x weekly to ensure adequate staffing to get residents to the dining room. Findings will be monitored by the Executive Director and reported to QAPI Committee for additional oversight. 5. Audit of activity attendance to be completed 5x per week x2 weeks then weekly x 4. Findings will be monitored by the Executive Director and reported to Quality Assurance Performance Improvement Committee for additional oversight.

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