Care Pavilion Nursing And Rehabilitation Center (February 6, 2015)

The nursing home’s environment failed to maintain and enhance the dignity and respect of the residents on seven nursing units. Findings included the following: During the initial tour of three west nursing unit accompanied by Employee E5, unit manager on February 3, 2015 at approximately 10:45a.m. the following was observed: Residents were noted to be sitting on tables in the dining room where a large flat screen television was mounted on the wall. The volume was noted to be very loud. Resident R308, an alert and oriented resident, resided in a private room that was directly next to the three west dining room and shared a common wall with it. The doorways to the Resident room and the dining room were noted to be diagonally opposite each other. The Resident stated in a private interview at the time that the television in the dining room was so loud that it was always like that, that it was always like that at night, that he told everybody about it. Observation of the dining room on Three West nursing unit on February 4, 2015 at 11:45 a.m. revealed approximately 20 Residents sitting at several tables throughout the room. Several of the residents had been identified as cognitively impaired by Employee E5, Three West registered nurse unit manager during the initial tour of the previous day. The television was on and the volume again was very loud. A table on one side of the room was set with sandwiches, salads, bottles of sodas and other items. Approximately 8 nursing staff members, including the unit manager were observed standing in front of the table holding plates and were in the process of serving food to themselves. The table was in full view of Residents who were sitting at tables across from them. The staff noted the surveyor and began to leave the room carrying plates of food. Employee E5 stated in an interview at 11:50 a.m. on that same date that the Residents had not yet eaten and were in the dining room waiting for their lunch at that time.

Based on observation, review of clinical record and resident and staff interviews, it was determined that the nursing staff failed to accommodate one resident’s need for a safe and comfortable wheelchair. Findings include: Review of Resident R298’s clinical record revealed the Resident was admitted to the nursing home and was moderately cognitively impaired. Continued review of revealed a Minimum Data Set dated November 9, 2014 which indicated a diagnosis. Further review of the MDS revealed that Resident R298 required staff supervision for transfer, dressing, ambulation, eating and used a wheelchair for mobility. Additionally the resident was frequently incontinent of bladder and required extensive assistance of staff for hygiene. An Occupational Therapy Evaluation completed in August 2014 stated that the Resident always used a wheelchair. The left armrest of the wheelchair was noted to have an elastic bandage wrapped around it, the padded portion of the armrest had slipped off and observed to be on the inside of the chair.