| 46 |
GREENBRIAR HEALTHCARE |
305005 |
55 HARRIS ROAD |
NASHUA |
NH |
3062 |
2018-12-19 |
725 |
E |
0 |
1 |
P2R411 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, it was determined that the facility failed to ensure sufficient staffing to provide nursing care for 16 residents out of a facility census of 234 residents. (Resident identifiers are #15, #18, #27, #30, #78, #79, #89, #91, #140, #164, #165, #177, #190, #196, #203, and #535.) Findings include: Resident #165 Interview on 12/13/18 at 9:53 a.m. with Resident #165 revealed that there were not enough staff and that at times it took hours for nursing staff to answer call lights. Resident #91 Interview on 12/13/18 at 10:06 a.m. with Resident #91 revealed that on early mornings between 5:00 a.m. to 6:00 a.m. the call lights took up to 2 hours to be answered. Resident #140 Interview on 12/13/18 at 10:27 a.m. with Resident #140 revealed that weekend nursing staff are short, 3-11 shift would have 3 nursing staff on the floor (5-2 unit) and most times they do not get showers. Resident #30 Interview on 12/13/18 at 10:40 a.m. with Resident #30 revealed that most nights, it took 3 hours to get Resident #30 to be assisted back to bed because of short nursing staff. Resident #30 stated that they need the assistance to go back to bed. Resident #30 stated that there were 2 LNA's (Licensed Nursing Assistant) most nights. Resident #89 Interview on 12/13/18 at 11:53 a.m. with Resident #89 revealed that Resident #89 states that there were not enough nursing staff. Resident #18 Interview on 12/13/18 at 1:13 p.m. with Resident #18 revealed that the facility needs more nursing staff and that nursing staff were worst at night as they had one LN[NAME] Interview on 12/14/18 at 6:30 a.m. with Staff L (LNA) confirmed that there was one LNA scheduled most 11-7 (Night) shifts. Staff L states that the 5-3 unit residents need more assistance, staffing was unsafe and call lights were going to be answered when they were available to do so and residents had to wait. Resident #27 Interview on 12/14/18 at 8:11 a.m. with Resident #27 revealed that the facility was short of nursing staff. Resident #27 stated that they had to wait for 1-2 hours on 3-11(Evening) and 11-7 (Night) shifts. Resident #27 stated that there were 2 LNA's on 3-11 and 11-7 shifts on 5-2 unit. Resident #78 Interview on 12/14/18 at 8:44 a.m. with Resident #78 revealed that the facility were short staff and it took an hour to answer the call light on all shifts. Resident #535 Interview on 12/14/18 at 9:06 a.m. with Resident #535 revealed that Resident #535 had to spend nights in their day clothes as no one got them ready for bed between 8:00 p.m. to 10:00 p.m. Resident #164 Interview on 12/14/18 at 10:09 a.m. with Resident #164 revealed that it took a long time for nursing staff to answer call lights and that Resident #164 felt that there were not enough staff on the unit (5-2 unit). Resident #190 Interview on 12/14/18 at 1:16 p.m. with Resident #190's family member revealed that there main concern was staff shortage. Family member stated that they had to do care for Resident #190 because the unit (Building #1 unit) was short staffed. Interview on 12/19/18 at 12:54 p.m. with Staff K (Staff Development Coordinator) revealed that the 5-3 unit residents were more acute and needed more assistance. Staff K was unable to provide more information on how the facility assess's the level of assistance that the residents need and how to appropriately staff in regards to the resident needs. Interview on 12/14/18 at 10:35 a.m.with Resident Council had 11 Residents present representing 3 different units in the building. When asked if Facility staff listened about grievances, Resident #140 responded with: The staff will listen and respond back, but not always timely. Resident #72 added: but the next step is actions, and those seem to be rarely taken. Resident #138 stated: when waiting for a call bell to be answered you can wait a half hour or more without anyone to even check to see if you are safe; Activities staff has been doing more and more to help other staff members in the building; i.e. (A greater) percent of the transporting of people to meetings. Resident #72 stated: There seems to be a shortage of people working in the Kitchen. They always seem to be 2 or 3 people short in the kitchen. Resident #72 also said there seems to be a lack of supervision in the kitchen, why else would we get such poor (food) service. There is a lot of turnover in the Kitchen. The turnover is incredible, in my lifetime of working, I've never seen turnover this bad. Resident #140 stated: that Monday through Friday (staffing) is bad, the weekends are brutal. The question was raised by a Resident as to who is managing the kitchen. Resident #72 said: They should have a person in the kitchen that knows the business inside and out so that they can tell staff what they should be doing. Resident #72 has also observed desserts to be uncovered during transport and was worried that dust or crumbs from carts or trays could get into those uncovered desserts. Resident #72 also stated: There are people in management throughout the entire organization who seem to lack experience. Resident #72 stated that on Thanksgiving Day there were 6 LNA's on the one floor because there were so many families on the unit. This resident further stated that ordinarily there were one or two aides on the unit. Interview on 12/18/19 at 1:09 p.m. with the Family Council revealed the family members present all said they need to provide activities of daily living such as feeding, grooming, and toileting to their family member residents when they visit. Interview on 12/14/18 with a family member revealed that there's a staffing shortage on the West Wing in building one. This family member stated that residents go for long periods of time without being changed after they've deficated or urinated in their disposable diapers. This family member said that the lack of sufficient staff is particularly apparent on weekends. In addition this family member reported having had to change their own spouse because of a shortage of available staff. In addition this family member reported that there's a lack of available staff to provide assistance to residents who need help during meals. Some residents, according to this family member, have missed eating altogether during a meal because of a lack of staff asssistance. Review of the minutes of a 11/27/18 meeting of the Resident's Food Committee noted cold food being served on unit 5-3. The Resident's Food Committee notes of the 11/27/18 meeting further stated that on unit 5-3 there's not enough nursing staff available to serve trays no one is there to pass out trays resulting in residents receiving cold food. Resident #203 Observation on 12/13/18 from approximately 12:30 p.m. to 12:45 p.m. of room [ROOM NUMBER]'s call light was on for assitance. During this observation, the light was visibly flashing and the sound was heard. It was observed that 5 different staff members walked past this room without entering. Interview on 12/13/18 at approximately 12:45 p.m. with Staff A (Unit Manager) stated that, Everybody answers lights. Resident #64 Interview on 12/14/18 at approximately 9:50 a.m with Resident #64 revealed the following statement, It takes too long for people to answer my call light, sometimes up to an hour. The food is always cold and it takes too long for anybody to warm it up. Resident #165 Interview on 12/14/18 at approximately 10:00 a.m. with Resident #165's family member revealed that sometimes when visiting the call light goes off for an hour without staff entering the room. Resident #165 also stated that at 6:00 a.m. on a regular basis staff can take up to an hour to answer call light. Resident #15 Interview on 12/13/18 at approximately 10:50 a.m. with Resident #15 revealed that Resident #15 stated that the facility was very short staffed. Resident #15 stated that food was frequently served cold and that if asked the nursing staff would heat it up but that Resident #15 did not ask the staff to heat up food because they were already so busy and that would take them away from their work. Resident #61 Interview on 12/13/18 at approximately 10:10 a.m. with Resident #61 stated that the facility was very short staffed. Resident #61 stated that their roommate, who was non interviewable, had to wait long periods of time for help. Resident #61 stated that they felt bad for their roommate and tried to help them but that the staff got upset when they tried to help their roommate. Resident #61 stated that it was for that reason that they were looking to transfer to another facility. Resident #79 Interview on 12/13/18 at approximately 11:45 a.m. with Resident #79 revealed that Resident #79 stated that the facility was very short staffed and that the residents had to wait for long periods of time for assistance. Resident #177 Interview on 12/13/18 at approximately 11:40 a.m. with Resident #177 revealed that Resident #177 stated that the facility was very short staffed and that residents had to wait long periods of time for assistance. Resident #196 Interview on 12/14/18 at approximately 8:45 am with Resident #196 revealed that Resident #196 stated that the facility was very short staffed. Resident #196 stated that the 11-7 shift was extremely short staffed and that they have had to wait over an hour for assistance. |
2020-09-01 |