Health inspection·July 31, 2023

F725 §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure patient safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each patient, as determined by patient assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s patient population in accordance with the facility assessment required at §483.70(e). §483.35(a) Sufficient Staff. §483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all patients in accordance with patient care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. §483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. T22 72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. § 72329.2 Nursing Service - Staff. (a) Nursing service personnel shall be employed and on duty in at least the number and with the qualifications determined by the Department to provide the necessary nursing services for patients admitted for care. The Department may require a facility to provide additional staff as set forth in Section 72501(g). On 6/8/2023, at 8:50 am, an unannounced visit was made to the facility to investigate a complaint regarding quality of care and staffing. The facility failed to provide sufficient qualified nursing staff, including certified nursing assistants (CNAs), in accordance with the facility's policy and procedures titled "Nursing Services and Sufficient Staff," by failing to: a. Ensure the duties of the Infection Control Nurse (ICN, a nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment), Director of Staff Development (DSD) and Treatment Nurse (TXN) were fulfilled due to assigning the roles to one person. b. Certified Nursing Staff requirements were met on 5/21/2023 in accordance with the Facility Assessment. These failures had the potential to result in a decline in the patients’ physical and psychosocial well-being due to poor quality of care and staff burnout. a. During an interview on 6/8/2023, at 10:15 a.m., the IPN stated he started working as the IPN since 6/1/2023. The IPN stated he did not receive any report from the previous IPN, so he had to start from "scratch." The IPN stated he did not start any surveillance of infections in the facility, or any monitoring of the antibiotics being prescribed to the patients. The IPN stated he had to cover for the newly appointed DSD, who was on vacation until 7/2023, and cover for the wound care nurse, who was on vacation for a week from 6/5/2023. In addition, the IPN stated he has created the schedule for Certified Nursing Assistants (CNAs) as part of his DSD role. The IPN stated he has sufficient CNAs to put on the schedule. IPN stated the facility currently does not utilize Registry agencies (provide staff on a contractual basis) for emergency staffing, because many staff were willing to "help out." During a concurrent interview with the IPN and a review of the facility's job descriptions for the ICN, DSD, and TXN on 6/9/2023, at 9:56 a.m., The IPN stated he was unable to perform all clinical, administrative, and monitoring duties and responsibilities of the ICN. The IPN stated he was unable to perform all the general duties and responsibilities of the DSD related to orientation, training, and administration. The IPN stated he was unable to perform all the duties and responsibilities of the TXN. The IPN stated due to the time constraints and multiple roles assigned to him. The IPN stated he was unable to perform fulfill all the duties of each position. During an interview on 6/12/2023, at 2:50 p.m., the DON stated the ICN must conduct an accurate and complete surveillance of the infections in the facility, including monitoring of the patients with the signs and symptoms of communicable disease and the response to treatments to be able to prevent possible transmission of infections. The DON stated the DSD not having enough time to identify the learning needs of the staff could lead to incompetent staff related to lack of the necessary in-services. DON stated it was important to ensure competent wound care nurses to prevent the deterioration of patients’ wound/s. The DON stated inaccurate assessments of the pressure injury (pressure ulcer/injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) could lead to incorrect treatments. A review of the facility's Job Description for ICN indicated the following duties and responsibilities: 1. Performs patient assessments for appropriateness of patient's care about infection control and adherence to isolation policies and procedures. 2. Performs clinical rounds for surveillance to verify status of patient, treatment, necessary follow-up for care needs and staff development, as well as, to ensure nursing personnel's performance is in accordance with the infection control standards. 3. Surveillance rounds to examine environmental factors that may impact on infection control issues. 4. Reviews culture reports and follow-up procedures. 5. Evaluates data for indicators of cause of infection. 6. Provides monthly summary of surveillance sheets (Monthly Infection Reports) to the Infection Control Committee. 7. Attends Infection Control Committee meetings and gives a summary of infections as to the type and number of infections acquired by patients and/or staff 8. Monitors staff performance utilizing rounds and review of surveillance reports, nursing progress notes, timeliness of obtaining cultures, and timeliness of physician notification. During a review of the facility's Job Description for DSD, it included, but was not limited to, the following duties and responsibilities: 1. Assists in providing job-specific training for all employees 2. Assists in the assessment of the clinical skills of the Certified Nursing Assistant 3. Assists in the assessment of the clinical skills of the Licensed Nursing Staff 4. Assists in the planning and implementation of the orientation process and the continuing education for the new employee During a review of the facility's Job Description for TXN, it included, but was not limited to, the following duties and responsibilities: 1. Identifies, manages, and treats specific skin disorders and primary and secondary lesions. 2. Provides input on assessment and diagnostic services using techniques including observation, inspection, and palpation. 3. Completes weekly skin assessment of patients and records results with assessment. 4. Provides information to patient and family members on prevention techniques and other ways to maintain or improve general health and psychosocial status of the patient. 5. Provides written and/or oral reports and recommendations to attending physician and completes weekly skin reports for the DON. During a review of the facility's policy and procedures, titled "Nursing Services and Sufficient Staff," dated 8/26/2022, it indicated the facility must supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all patients in accordance with patient care plans: 1. Except when waived, licensed nurses; and 2. Other nursing personnel, including but not limited to CNAs. b. During an interview on 6/8/2023, at 10:46 a.m., Registered Nurse Supervisor 1 (RNS 1) stated the facility did not have any CNA shortage, because most staff were willing to work half of a shift on top of their regular shift to cover for the shift that was short-staffed. RNS 1 stated there was a day in 5/2023 when 2 CNAs had called in sick and only 1 CNA was present at the start of shift. RNS 1 stated the previous DSD did not respond to her calls, so RNS 1 called the Administrator (ADM). RNS 1 stated the ADM came and brought his family member (CNA 8) who was not yet an employee of the facility at the time, "to help out" with patient care. RNS 1 stated CNA 8 was an experienced CNA for years and her employment documents were processed after 5/21/2023. RNS 1 stated facility’s administrative staff did not utilize any Registry staff, because "they just give meds, walk past the call lights, and don't give enough care." During an interview on 6/8/2023, at 11:15 a.m., RNS 1 stated she wanted to clarify her earlier statements as she had forgotten some details. RNS 1 stated CNA 8 did not do patient care and was only instructed to answer call lights and pass the meal trays on 5/21/2023. During an interview on 6/8/2023, at 11:23 a.m., The ADM stated he received a call from CNA 1 on 5/21/2023 to inform him that the morning shift was short of CNAs. The ADM stated he asked CNA 8 if she would be willing to help and she agreed. The ADM stated when they (the ADM and CNA8) got to the facility, CNA 8 started working immediately by answering call lights and helping patients get up from bed. The ADM stated she was assigned to an area, changing patients’ adult briefs, assisting with showers, and other activities of daily living (ADLs, such as, transfers, eating, personal hygiene, toileting, etc.). The ADM stated CNA 8 completed the shift and they both left the facility around 4 p.m. The ADM stated CNA 8 was oriented within the following week and has worked again at the facility for 1 or 2 days since then. The ADM stated the facility was not utilizing registry (a staffing agency which provide nursing personnel per shift or temporarily) staff because of having "bad experience with them" and not being able to financially support Registry staffing. During an interview on 6/8/2023, at 12:57 p.m., the Director of Nursing (DON) stated RNS 1 called her early morning of 5/21/2023 to inform her regarding the shortage of CNAs in the morning and DSD 1 not responding to her calls or messages. The DON stated when she got to the facility, RNS 1 and CNA 1 were still attempting to find CNAs to come to work. The DON stated the ADM, CNA 8, and the Business Office Manager (BOM) arrived at the facility after, but the DON stated CNA 8 "did not help out" with patient care. The DON stated when there were 3 CNAs in the facility, she told the ADM and CNA 8 that staff were okay and they could go home. The DON stated the ADM and CNA 8 left shortly after. During an interview on 6/8/2023, at 2:24 p.m., CNA 9 stated on 5/21/2023, she came to the facility at 10 a.m., because she agreed to work earlier than her usual shift from 2 p.m. - 10 p.m. due to the CNA shortage. CNA 9 stated when she arrived at the facility, CNA 1, CNA 2, and CNA 8 were changing adult brief (disposable underwear), turning patients, getting patients out of bed, helping with feeding patients, and passing the meal trays to the patients. During an interview on 6/9/2023 at 2:15 p.m., CNA 2 stated on 5/21/2023, CNA 1 was already in the facility when she arrived and was making phone calls to see who would help them. CNA 2 stated ADM and CNA 8 then arrived at the facility. CNA 2 stated CNA 8 helped the CNAs with passing breakfast trays, changing patients' adult briefs and clothes, answering call lights, assisting patients with eating, providing showers, and transferring patients from bed to chair. CNA 2 stated it was her first time to meet CNA 8, and CNA 8 was "really good, very attentive to the patients." CNA 2 stated CNA 8 was "really good with showers," "can change patients’ adult brief by herself," and "did not ask me for help with turning." CNA 2 stated CNA 8 would ask them who could get out of bed, who could stay in bed, and who could eat. During a concurrent interview and record review on 6/12/2023, at 10:50 a.m., ADM's signed Declaration Statement was reviewed. ADM stated CNA 8 asked CNA 1 what she could do to help. ADM stated he had forgotten that he and CNA 8 left the facility on 5/21/2023 on or before 10:30 a.m. because DON notified them that "everything was under control," and they could leave. The ADM stated he did not know why CNA 8's timecard reflected that CNA 8 started at 7 a.m. and left at 3:30 p.m. on 5/21/2023. During an interview on 6/12/2023, at 11:51 a.m., Payroll Staff 1 (PS 1) stated CNA 8 was not officially an employee of the facility when she worked on 5/21/2023 to help CNAs due to the staffing shortage. PS 1 stated DSD 1 instructed her to put input CNA 8's work hours in the system, although PS 1 did not see any documented evidence of CNA 8's actual sign-in/sign-out. PS 1 stated CNA 8 came the following Monday and PS 1 did the background check for CNA 8's employment at the facility. During a review of the facility's Facility Assessment document, titled "Facility Capacity and Average Census," dated 8/26/2022, the facility's patient capacity was 48 and the average census was 32. During a review of the facility's Facility Assessment document, titled "Staffing Plan & Individual Staff Assignments," dated 8/26/2022, indicated for facility census of 33-48 patients, there must be 5 CNAs for morning shift. The document indicated for facility census of 32 and below, hours would be reduced (Removing RNS and a CNA from each shift). During a review of the facility's policy and procedures, titled "Nursing Services and Sufficient Staff," dated 8/26/2022, indicated the facility must provide sufficient staff with appropriate competencies and skill sets to assure patient safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each patient. The policy indicated the facility ' s census, acuity, and diagnoses of the patient population would be considered based on the facility assessment. During a review of the facility document, titled "CNA Daily Assignment Sheet," dated 5/21/2023, it indicated the census was 42. The facility failed to ensure sufficient qualified nursing staff, including CNAs, in accordance with the facility's policy and procedures titled "Nursing Services and Sufficient Staff," by failing to: a. Ensure the duties of the ICNDSD and TXN were fulfilled due to assigning the roles to one person. b. Certified Nursing Staff requirements were met on 5/21/2023 in accordance with the Facility Assessment. These failures had the potential to result in a decline in the patients’ physical and psychosocial well-being due to poor quality of care and staff burnout. This violation jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of all patients residing in the facilities.