complaint·July 11, 2022

After they provided a shower chair, the facility said that they had an extra one that was already provided. LPA Olson reviewed R1’s Resident Appraisal and Needs and Services Plan which state that R1 would receive showers twice a week. LPA reviewed July 2021 shower schedule which indicated that R1 refused a shower 7/6/21 and 7/22/21 and was only showered once on 7/27/21 since moving in on 7/5/21. LPA interviewed the Wellness Director at the time who stated they showered Resident 1 at least once in July but didn’t track it. Per the needs and services plan, the resident was not showered twice a week to meet their needs. Based on LPA interviews and record review the allegation is deemed Substantiated at this time. On the allegation: Staff not providing assistance to residents. Reporting Party (RP) stated that R1 would use the provided pendant to call for assistance. RP provided an example that R1 would use their pennant to call staff while on the toilet, yet staff wouldn’t respond. RP stated that family would have to call the facility directly, and receptionists would page care staff to go and assist R1. LPA interviewed 2 Facility Receptionists who confirmed that family’s and residents call the front desk often to ask for care staff to be paged for assistance due to staff not responding to their pennant timely. Staff interviews confirmed they are paged multiple times per shift by the receptionist to assist residents. LPA reviewed call logs from 7/13/21-7/16/21 and 8/3/21-8/6/21 which revealed R1 pressed their pendant a total of 60 times. 24/60 (40%) of R1’s calls were answered in 15 minutes or less, which all staff confirmed is the facility’s goal response time. 12/60 (20%) of R1’s calls were answered within 16-29 minutes, 4/60 (6.6%) of calls were answered within 30-45 minutes, and 20/60 (33.3%) of R1’s calls were not answered at all (remained unanswered). Based on staff and resident interviews, most felt there was not enough staff to meet the resident’s needs and respond timely to the call buttons. Based on LPA interviews and record review the allegation is deemed Substantiated at this time. Exit interview, report given, deficiencies cited on 9099-D, Civil Penalty of $250 is assessed for repeating the same violation within 12 months, appeal rights given. RP stated that maybe R1 needed more care but the facility never informed them. RP stated they had to call the facility for updates and ask what was going on. R1’s physician’s report dated 7/1/21 indicates a diagnosis of hypertension, hypercholesteremia, mild cognitive impairment, needs assistance with bathing, needs minimal assistance with dressing/grooming. R1’s Resident Appraisal dated 7/6/21 indicates R1 uses a walker, needs stand by assistance for transfers for safety, needs stand by assistance for transferring to the toilet, needs physical assistance with bathing twice a week, needs stand by assistance with dressing and needs clothing set up, and needs frequent checks to ensure safety. All staff interviewed stated they try to provide assistance to residents as quickly as possible and respond to call buttons as quickly as possible. Most residents interviewed stated staff provided assistance to meet their needs. A care note for R1 from 7/15/21 at 5:40am indicates a med tech responded to R1’s call and was observed sitting on the bathroom floor with no visible injuries, but was confused, so staff called 9-1-1. The resident left the hospital in stable condition with no injuries but some confusion. An Incident Report indicates on 8/5/21 at 11:45pm, R1 was observed on the floor by staff during a check. R1 complained of back pain and 9-1-1 was called for medical attention. The facility was unable to provide detailed care notes for R1 showing that frequent checks were completed. The electronic system staff use to track resident needs and the care provided only prompts once per shift, and not multiple times per shift; therefore there are no records showing how often each care task was performed. Based on the evidence obtained, there was insufficient evidence to substantiate the allegation that a lack of assistance resulted in a fall. Therefore the allegation is deemed unsubstantiated at this time. An Advisory Note for Technical Assistance was issued to recommend implementing a system that has more accurate data for tracking care completed. Exit interview, Technical Assistance issued, report emailed.