cms_UT: 23
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 23 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2017-05-03 | 353 | E | 1 | 0 | 74IB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined the facility did not employee a sufficient number of staff to provide the cares to the resident as care planned. Specifically, 3 out of 11 residents stated that there was not enough staff, 1 resident did receive timely assistance with her activities of daily living, 2 staff members stated that there was not enough staff to complete their tasks as assigned, and the Resident Council complained of call lights not being answered timely in January, February, (MONTH) and April. Resident identifiers: 1, 7 and 10. Findings include: 1. On 5/3/17 at 8:29 AM, resident 1 was interviewed. Resident 1 stated that his call light had not been answered for an hour at times. 2. Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 7's medical record was reviewed on 5/3/17. Resident 7's nurses notes documented that resident 7 was incontinent of bladder and continent of bowel. A quarterly Minimum Data Set (MDS) assessment dated [DATE] for resident 7 was reviewed. Staff documented on the MDS that resident 7 was always incontinent of bladder, but always continent of bowel. On 5/3/17 at 11:10 AM, an interview was conducted with resident 7 regarding the cares she received at the facility. Resident 7 stated that there were not enough staff at the facility. Resident 7 stated that she was incontinent and that after she soiled her brief, she would press her call light to alert the staff that she required assistance with a brief change. Resident 7 stated that after she pressed her call light, she would have to wait at least an hour for staff to assist her because staff are more interested in gossiping than they are in helping me. 3. Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 10's medical record was reviewed on 5/3/17. A quarterly MDS assessment dated [DATE] for resident 10 was reviewed. Staff documented on the MDS that resident 10 was always incontinent of both bowel and bladder. Resident 10's care plan and nurses notes documented that resident 10 was incontinent at times, and required the use of briefs. Resident 10's Activities of Daily Living (ADL) flow sheet indicated that resident 10 required extensive assistance with bed mobility, toileting and grooming. On 5/3/17 at approximately 8:27 AM, an observation was made of resident 10. Resident 10 was laying in her bed with her eyes closed, and her head tilted to the right. Resident 10 had a full cup of orange juice on her bedside table. There was an odor of urine in the hallway outside of resident 10's room. On 5/3/17 at approximately 10:14 AM, an observation was again made of resident 10. Resident 10 appeared to be in the same position as observed earlier, with her head tilted to the right, and a full cup of orange juice on her bedside table. There was an odor of urine in the hallway outside of resident 10's room. On 5/3/17 at 11:00 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that she was assigned to provide cares for resident 10 that day CNA 1 also stated that she had arrived at work at 6:00 AM, and had changed resident 10's brief shortly after she arrived, at approximately 6:45 AM. CNA 1 stated that resident 10 had refused to get out of bed after that, and that the CNA had offered a snack and checked resident 10's brief at approximately 10:45 AM. The CNA confirmed that it had been approximately 4 hours since she had checked on resident 10 to determine if she required incontinence cares. Immediately following the interview with CNA 1, the CNA was observed to enter resident 10's room to provide incontinence care. There was a strong odor of stool in the hallway outside of resident 10's room. 4. Review of the Resident Council Meetings from (MONTH) through (MONTH) (YEAR) were reviewed. The Resident Council complained of the following: a. 1/11/17: Call lights being slow to be answered at times. Resident state early afternoon and also after 10 PM. The facility staff documented, staff inserviced on call light response time being no longer than 2 minutes. Note: An in-service memorandum, dated 1/18/17, from the facility Staff Development Coordinator to the Nursing Staff was attached to the Resident Council complaint which documented, .Call lights must be answered within 2 minutes of when they are pushed. Call lights must be within reach at all times when a resident is in their rooms (sic). All nursing staff are responsible for answering call lights. b. 2/13/17: Call light (sic) are slow to be answer (sic) mostly weekends and after dinner. c. 3/14/17: Call lights are slow to be answers (sic) mostly weekend and after dinner. SDC (Staff Development Coordinator) is reminding staff to answer call light ASAP (as soon as possible. The facility staff documented, Systems in play, call lights improving will continue to monitor. Note: An in-service memorandum, dated 3/14/17, from the facility Staff Development Coordinator to the Nursing Staff was attached to the Resident Council complaint which documented, .Call lights must be answered within 2 minutes of when they are pushed. Call lights must be within reach at all times when a resident is in their rooms (sic). All nursing staff are responsible for answering call lights. If multiple call lights are going off but you do not have enough time to help someone, please answer the call light, let the resident know a time frame in which you will be able to assist them, ie: 'you are next in line to get ready for bed' or 'I should be done in the dining room in about 10-15 min (minutes).' THEN: Follow through with what you say. If you are forgetful, keep a piece of paper or notepad in your pocket and write things on it that you must remember. There are times when it is very busy and it can be overwhelming to get to all of the call lights. Keeping good communication with the residents will make them more understanding and patient as things are getting completed. d. 4/5/17: Call light (sic) are often slow to be answered mostly after dinner. Residents state this is better. Note: An in-service memorandum, dated 4/3/17, from the facility Staff Development Coordinator to the Nursing Staff was attached to the Resident Council complaint which documented, .Call lights must be within reach of the resident's reach at ALL times when they are in their rooms. There is NO exception. Call lights must be answered within 2 minutes of when they are pushed. Call lights must be within reach at all times when a resident is in their rooms. All nursing staff are responsible for answering call lights. Call lights must be answered within 2 minutes of when they are pushed. Call lights must be within reach at all times when a resident is in their rooms (sic). All nursing staff are responsible for answering call lights. | 2020-09-01 |