Arnot-Ogden Medical Center Residential Health Care Facility

epn Based on observations, resident and staff interviews, and record reviews conducted during an Abbreviated Survey (complaint #NY00109574) completed on 1/6/12, it was determined that for three of four residents reviewed for call light placement or response, facility staff did not provide services with reasonable accommodation of individual needs and preferences. This resulted in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by, but not limited to, the following:

1. Resident #1 was admitted to the facility for rehabilitation services on 11/15/11 with diagnoses including cardiomyopathy, aortic valve replacement, asthma, and an infected pressure ulcer on the buttocks. Review of the plan of care, dated November 2011, revealed that the resident is at risk for falls. Staff is to anticipate and intervene to prevent future falls. Staff is also expected to keep the resident's call bell in reach, to encourage use, and to respond promptly. Review of the Minimum Data Set (MDS) Assessment, dated 12/5/11, revealed that the resident is cognitively intact.

The Vision Link call data (computerized record) provided by the facility shows that Resident #1 waited 41 minutes on 11/19/11 at 7:10 p.m., 18 minutes on 11/22/11 at 8:09 a.m. and 28 minutes at 5:13 p.m. for assistance. This call data showed 58 other call light responses which ranged from 16 to 96 minutes.

When interviewed on 12/9/11 at 3:30 p.m., the Social Worker (SW) stated she recalled one incident with Resident #1, when he was frustrated by the lack of attention for a few hours that she thought was overnight.

During a telephone interview on 12/19/11 at 6:15 p.m., a family member reported that Resident #1 used his personal cellular phone to call the hospital main number on 11/19/11 at 7:19 p.m. and again on 11/22/11 at 7:45 a.m. and 5:45 p.m. because staff did not respond to his call light when he needed assistance. On one of these occasions he was told not to tell his family. The family member also reported that when Resident #1 reported this to Administrator, the Administrator denied that this could happen.

During an interview on 12/28/11 at 12:35 p.m., the Administrator and Registered Nurse (RN) both stated that they were not aware of the three calls made to the front desk by Resident #1.

When interviewed on 1/6/12 at 12:50 p.m., the Director of Nursing (DON) stated that her expectation for call light response is less than five minutes. The DON stated that she was aware of one time when Resident #1 called the hospital main number for assistance and said she had asked the SW to look into it. The DON stated that on 11/19/11, Resident #1 received a respiratory treatment at 7:30 a.m. On 11/22/11, treatments were administered at 6:00 a.m., 10:53 a.m., and also at 7:30 p.m. after the family notified the nurse at 7:00 p.m. that the resident had not received his treatment.

epn In addition, the 11/16 to 11/24/11 Vision Link call data record for Residents #3 and #4's (roommates) call bell revealed 21 call light response times of 16 to 47 minutes.

2. Resident #3's MDS Assessment, dated 12/19/11, revealed that the resident is cognitively intact. In an interview on 12/9/11, the Administrator and Registered Nurse (RN) both stated that the resident is interviewable.

When interviewed on 12/9/11 at 3:00 p.m., the resident stated that she does not have full Range of Motion in her right shoulder and could not reach the call bell. In an observation at this time, the resident attempted to reach her call bell and could not reach it. Resident #3 reported that she has yelled and screamed for assistance when she cannot reach the call bell. She stated that she does not want to be left on the bedpan for a long time because it hurts.

3. Resident #4 has diagnoses including Alzheimer's dementia, chronic lower back pain, and fibromyalgia. Review of the MDS Assessment, dated 12/14/11, revealed that the resident's cognitive skills for daily decision making are severely impaired.

In an interview on 12/9/11 at 2:00 p.m., the RN stated that the resident does use her call bell to request assistance.

In an observation on 12/9/11 at 3:15 p.m., Resident #4's call light was placed on the bed above her left shoulder. When asked at this time if she could reach her call bell, the resident said she could not and would not know what to do if she needed help.

[10 NYCRR 415.5(e)(1)]