SEATTLE, WA-BALLARD CENTER

Failures caused harm to Residents 1, 2, 4, 16, 3, 10, 11, 13 and 14 and placed the other residents at risk for harm related to ongoing abuse and neglect. 

Administration’s lack of oversight and ensuring staff were adequately trained in accessing, reading, and implementing each resident’s care plan, caused harm to Resident 1 and 2 who suffered physical and psychosocial harm related to the incidents and placed all three residents (Residents 1, 2 and 3) at increased likelihood of serious harm, injury, impairment and/or death related to avoidable accidents and falls.

On 02/01/2022 at 11:30 AM, Resident 4 stated she was neglected and felt abandoned by staff so many times. Resident 4 stated that on 01/23/2022 at around 2:00 PM, she called and asked for staff to bring her use a bedside commode. However, Resident 4 stated she had waited for at least 2-3 hours until any staff helped her, and she had peed and pooped herself while waiting. According to Resident 4, it was very humiliating and embarrassing, and this was not the first time that this had happened. Resident 4 stated she had reported these concerns of not getting staff assistance for at least 2-3 hours, and sometimes not at all almost every day and every month to the facility administration, but nothing had happened, They just ignore us and don’t care about us.
During the interview, the resident appeared visibly upset and stated that she was frustrated and angry about the situation and felt helpless because it wasn’t just her who experienced these problems. Resident 4 further stated that she had developed skin breakdown and rash on her private areas and buttocks area because of this on-going neglect of care.

On 02/01/2022 at 10:30 AM, Resident 3 stated, Residents here are being neglected, including myself. According to Resident 3, she would ask and call for staff assistance with toileting and brief change and including simple requests for water, medicine and going to bed. Resident 3 said she had to wait hours to get help and sometimes staff would not return to the point where I’ve been sitting on my own waste for at least 2-3 hours and sometimes longer.

On 02/01/2022 at 11:55 AM, Resident 16 stated that on 01/19/2022 and 01/20/2022 morning and afternoon shift (could not recall specific time), she had to wait for at least 1-2 hours to get staff to change her brief. Resident 16 stated she had urinated and had a bowel movement, so she had to call staff to change her. However, Resident 16 stated no staff person came for at least 1-2 hours and she was sitting at her own waste that made her itch and angry to a point where she had to file a complaint. According to Resident 16, the situation made her felt humiliated and neglected and was concerning enough because it happens all the time here.

On [DATE] at 2:30 PM, Staff K, NAC stated she was a new employee and did not know that Resident 3 required two staff people during care and transfers. Staff K stated she was not aware of the care plan or the kardex (care directives) and she does not know where to locate them. According to Staff K, she did not receive any training or education related to the care plan and was just observing what other NACs had done.

On 02/09/2022 at 5:30 PM, both Staff B, Director of Nursing and Staff N, Licensed Practical Nurse/Staff Development Coordinator (LPN/SDC) stated the facility had no current process or system to train new employees (including Staff K, NAC) about the importance of reading and understanding each resident’s care plan, including how to locate and access them to ensure an effective and safe delivery of care. Both Staff B and Staff N stated that the facility’s lack of an effective system to educate and train staff about care plans and kardex, including the lack of supervision that resulted to accidents does require immediate actions, had placed the residents at risk for the likelihood of serious injuries, serious impairments and/or potentially death from avoidable accidents like falls.