The Minnesota Department of Health (MnDOH) identified a number of deficiencies at the Cook County North Shore Care Center after a visit to the facility in September. The Department of Health was conducting an inspection on behalf of the federal Centers for Medicare & Medicaid Services, a significant source of funding for the facility.
Dignity and communication
The Department of Health listed one deficiency as failure of nursing assistants to help a resident with daily care in a respectful manner that preserved his dignity by communicating properly with the resident.
“Resident 21” (R21) had dementia, severe cognitive impairment, and displayed “physical behavioral symptoms directed toward others.” The resident did not speak but appeared to be able to hear, communicate nonverbally, and follow some directives.
The care plan required nursing assistants to tell the resident what they were going to do, allow 10 seconds for him to process the information, and then be slow and gentle. One morning, Nursing Assistant A (NA-A) entered the room and told the resident s/he was getting him ready to go eat breakfast. The nursing assistant started to get him dressed when the inspector asked if he would be getting a bed bath. The nursing assistant said, “Well, he gets showers once a week,” and “I did a bath yesterday.”
Nursing Assistant B (NA-B) entered the room and turned on a fan that blew directly onto the resident. Nursing Assistant A said, “We need to wash him,” and went to the bathroom and got two washcloths wet. The inspection report says, “Without explaining the procedure, NA-A washed R21’s face, hands, and when NA-A attempted to wash under the arms R21 would push NA-A away when the washcloth touched the skin. The surveyor questioned NA-A if the washcloths had gotten cold. NA-B stated the washcloths were hot. NA-A stated, ‘Well, not now they’re not; they’re cold because of the fan blowing on them.’ NA-A then abruptly picked up a pink basin from the bedside stand, poured out the contents (care supplies) onto the shelf, and obtained hot water in the basin from the bathroom. NA-A returned to the bedside and washed under R21’s arms and the perianal area.
“During the cares NA-A and NA-B were having an inappropriate conversation regarding the surveyors [inspectors]. The NAs did not converse with R21 or explain any of the care procedures. Throughout the cares NA-A and NA-B talked over R21 with no eye contact, and R21 just stared at the ceiling.” The report later states that a registered nurse on duty told the inspector that nursing assistants were expected to communicate with residents and explain their procedures while caring for them.
Later in the report, the inspector noted that this resident’s current care plan did not instruct caregivers to brush his teeth, and during the inspection, no oral care was done. When the inspector asked about it, however, the nursing assistant brushed his teeth. Oral care is supposed to be done twice a day and as needed according to the condition of the resident’s mouth.
The hospital created a plan of correction and submitted it to the Department of Health to their satisfaction. The plan states, “NA-A was counseled by the facility administrator about the importance of communicating with residents as personal cares are provided. It was explained that we expect that residents will be treated with dignity and respect. Direct interaction with the resident is one way of showing dignity and respect.” The director of nursing also met with the nursing assistant and went over specific expectations for that resident as well as general expectations for all residents, including procedures for oral care. A plan was put in place to conduct clinical evaluations of the nursing assistant in 2014 and report the results to the Quality Assurance Committee.
Policies and procedures regarding maintaining resident dignity and providing oral care were discussed at a November 26 staff meeting. All nursing assistants were required to read and sign the oral care policy and procedure. Clinical performance evaluations will be conducted on the nursing assistant staff by the end of the year and twice in 2014 and the result will be reported to the Quality Assurance Committee. The status of each resident’s mouth will be evaluated once a week for four weeks and monthly for six months, with the results to be reported to the Quality Assurance Committee.
Privacy requests
Another deficiency regarded lack of adequate response to a request by two female residents at a resident council meeting to get help from female employees when using the bathroom, bathing, and dressing. The report states, “When a resident or family group exists, the facility must listen to the views and act upon the grievances and recommendations of residents and families concerning proposed policy and operational decisions affecting resident care and life in the facility.”
“Resident 28” had no cognitive impairment but required extensive help with personal care. She said she and about four other women had requested that they have female caregivers help them with personal care. The resident said, “They [facility staff] said we just have to accept it. They told us that.” She said that while the male aides “are nice and provide good care,” she preferred help from female aides.
Minutes from a January council meeting state that the hospital social worker referred them to a Minnesota Department of Health resident bill of rights document that outlined their right to refuse treatment or personal care. The minutes stated, “Some members asked questions and seemed satisfied with the answers.”
Care Center records show both male and female nursing assistants on duty on numerous shifts. The inspector spoke with Social Worker Hilja Iverson, who according to the report said that during those shifts, “the residents were told they could refuse care, but the facility could not guarantee when they would be accommodated for cares due to the other staff having their own residents.”
In an interview with the inspector, “Resident 12” said, “I have had to accept it. It makes me feel uncomfortable.” She said she does get a female caregiver for showers but not for other care. “They still wash your bottom. I would rather have a female, but it’s tolerable,” the report states. “I was married for 54 years, and only my husband saw my naked body.” Neither of the two residents’ care plans mentioned their preference for female caregivers.
The inspector spoke with “Registered Nurse A”, who said accommodating the requests was difficult. The report quotes the nurse as saying, “We do not have the staff. You can try to switch, but they have breaks.” The report goes on to say, “RN-A stated it would be reasonable to look at the issue and possibly look at scheduling changes.”
The hospital’s plan of correction included updating the care plans for both residents, noting that they prefer help from female staff when bathing and directing nursing assistant staff to ask for help from the charge nurse if needed in order to make those arrangements for that shift. Resident concerns or grievances will be followed up by filling out a concern form and initiating the formal grievance procedure. The process for doing this will be explained at a resident council meeting. The hospital social worker will regularly submit grievance files along with outcomes to the Quality Assurance Committee.
Cleanliness
The report noted that on a tour with the housekeeping supervisor, the ceiling vents in five resident bathrooms (each adjacent to two resident rooms) had a heavy accumulation of dust. It said, “Review of the duty list, provided by the housekeeping supervisor, revealed cleaning of the bathroom vents was not addressed, except for the men’s and women’s bathrooms by the staff locker rooms.” The housekeeping supervisor agreed that the issue needed to be addressed.
The hospital housekeeping staff cleaned the bathroom vents on September 27 and inspected all other exhaust vents and cleaned them as necessary. The housekeeping infection control policy was revised to require that staff check the fans weekly and clean as needed. The director of housekeeping will make sure the fans are being inspected and cleaned and will report this to the Quality Improvement/Peer Review Committee quarterly.
Posting staffing ratios
The report noted that the facility did not include nursing assistants on a required daily posting of the number of staff on duty each shift. That was corrected by modification of the form that is used. The postings will be reviewed each month for a year, with results to be reported to the Quality Improvement/Peer Review Committee.
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