Insufficient Nursing Staff Leads to Delayed Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure timely response to call bells and adequate care for residents, as evidenced by interviews and observations. During a Resident Council meeting, seven alert and oriented residents expressed concerns about delayed responses to call bells, with some residents waiting 30 minutes to over an hour for assistance. Residents reported staff being distracted by personal phone use, including using earbuds and talking on the phone while performing care. One resident mentioned being left wet for extended periods and not receiving assistance to get out of bed on weekends, leading to discomfort and prolonged periods in a wheelchair. Observations confirmed these concerns, with a call light in Room 233 remaining unanswered for 30 minutes, during which the Director of Nursing was notified. The resident in that room was found incontinent and at risk for skin breakdown. Additionally, during a dressing change, another resident was found lying in bed with a soaked adult undergarment and bed sheets, indicating prolonged exposure to urine. The LPN confirmed the resident had been in this state for an extended period. These findings highlight the facility's failure to maintain sufficient nursing staff to meet the residents' needs and ensure their well-being.
Plan Of Correction
All nursing staff are to be educated on resident rights, the cell phone policy, use of earbuds and answering call bells timely, by the Director of Nursing/Designee. Administrator will meet with the President/Vice President of Resident Council monthly to ask if they can attend Resident Council, to discuss if staff is answering call lights, completing incontinence care, and refraining from the use of cell phones and earbuds. Results of the discussion will be documented. An audit will be conducted to ensure staff are meeting residents' needs timely by the director of nursing/designee to include answering of call lights, incontinent care, and use of cell phones and earbuds by staff. The audit will be conducted by the DON/Designee by interviewing 3 residents per unit per shift 3 times a week for 4 weeks, weekly for 4 weeks and then 1 time per month ongoing. The audit will be monitored by the Administrator and results will be reported to the Quality Assurance Performance Improvement committee for review and recommendations.