KINGSPORT, TN- ORCHARD VIEW POST-ACUTE AND REHABILITATION CENTER

Based on facility policy review, medical record review, review of facility grievances, interview, and
observation, the facility failed to prevent neglect for 8 dependent residents (#1, #2, #3, #4, #5, #6, #7, and #8) of 10 dependent residents reviewed for abuse. The facility’s failure resulted in psychosocial harm for Residents #1, #2, #3, #4, and #6.

The facility was cited F-600 at a scope and severity of H, which constitutes Substandard Quality of Care.

During an interview on 5/26/2022 at 3:16 PM, the Assistant Director of Nursing (ADON) stated he was made aware of concerns with multiple residents being left saturated in urine for hours. He stated staff had him do observations on several of the residents and he observed multiple residents in bed saturated with urine and requiring a full bed linen change (exact dates unknown). The ADON stated he did not think the residents had received the proper care needed for the past couple of months. He stated Resident #2 had complained of her call light not being answered timely when she needed the bedpan and the resident had urinated on herself.

During a telephone interview on 5/23/2022 at 3:17 PM, Resident #1 stated she had been a resident at the facility, had multiple fractures, was non-weight bearing on the left side, and received therapy services. The resident stated she was discharged from the facility on 5/17/2022 to her home. Resident #1 stated the facility had call lights in the rooms for residents to use when they needed assistance. She stated nurses and CNAs were supposed to respond to the residents’ needs, but she had to wait 1 to 1 1/2 hours before staff would respond to her call light on night shift. She stated the facility had 1 CNA on night shift to care for the residents and she had to lay in her .own waste [urine and feces] . on night shift multiple times (exact dates unknown). She stated most of the nurses on night shift would not help the CNAs, .problem is the nurses want to sit around and the CNAs are over worked . The resident stated she made the Director of Nursing (DON) aware of her concerns and the DON informed the resident the facility was shorthanded and couldn’t get anyone to work. She stated there were normally 2 CNAs on day shift. Resident #1 had problems with staff
responding to her call light timely on day shift, depending on who was working, and she had been left in urine multiple times. Resident #1 stated .you can only hold your urine and bowels for so long when you are told you have to wait your turn. Lying in my pee and poop is definitely something I had never done before and don’t want to experience it again. It made me cry and I felt totally degraded .

During an interview on 5/23/2022 at 1:05 PM, Resident #2 stated night shift was not good, and the staff complained of being short staffed. The resident stated when she pushed her call light for assistance with the bedpan, she had to wait a long time for her call light to be answered .It happens on both shifts but worse on night shift. Six PM to midnight is bad and waited up to 2 hours for assistance .at times the CNAs will come in, turn the call light off, say they will come back, and do not return for several hours . Resident #2 stated she required a bedpan for urinating and having a BM (bowel movement) at times, and she was not always aware when her bowels moved. The resident stated she had been saturated with urine and feces on both shifts because staff had not answered her call light timely. The resident stated, .I hold it as long as I can. It makes me feel horrible, not human, and it is degrading to lay in urine and poop because I’m not receiving the care I need .

During an interview on 5/23/2022 at 12:00 PM, Resident #3 stated she was non-weight bearing and required assistance with toileting needs. The resident stated the night shift staff did not respond to her call light timely to be assisted with the bedpan. The resident stated .peed and pooped . on herself multiple times (exact dates unknown). The last time was on 5/22/2022 night shift. Resident #3 stated .there is not enough help at night to help us . Night shift is short staffed a lot of times with 1 CNA to care for all the residents. She stated when the staff did assist her with the bedpan, they left the room, waited for her to call for assistance to be removed from the bedpan, and she was left on the bedpan for a .long time . because staff do not respond to the call light. Resident #3 stated .pooped and peed .on myself it did not make me feel too good about myself.

During an observation and interview on 5/24/2022 at 4:33 PM, Resident #6 yelled out for someone to help him. The resident stated he needed to be changed. He stated he had his call light on for a long time and staff turned off the call light. He informed the staff he needed to be changed and he was informed a CNA would be with him shortly. Resident #6 stated he had been laying in a urine-soaked brief for over 2 hours. CNA #4 and CNA #9 then entered the room to provide care and the resident’s brief and under pad was soaked with urine with a strong urine odor present. Resident #6 stated he had not been checked or changed since 10:00 AM on 5/24/2022.

During an interview on 5/24/2022 at 4:45 PM, CNA #4 confirmed Resident #4 had not been changed since 10:00 AM (the resident’s brief was changed 6 hours and 33 minutes later at 4:33 PM) and stated, .it has been hectic today .