Other·May 22, 2024

WESTLAND HOUSE RECERTIFICATON SURVEY (8KR511) Exit Date 05/03/24 The following reflects the findings of the California Department of Public Health during a recertification survey Event # 8KR511 Representing the Department, HFEN # 48590 State Citation B was written REGULATORY VIOLATION(S): Federal Code of Regulations Title 42 F700 §483.25(n) Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. §483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation. §483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. §483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight. §483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails. On 4/29/24, an unannounced visit was conducted at the facility for a recertification survey. The facility failed to ensure the proper use of side or bed rails ((adjustable rigid bars attached to the side of a bed) for 25 of 25 sampled residents (Residents 122, 120, 175, 70, 73, 1, 79, 125, 72, 126, 71, 74, 76, 128, 171, 75, 172, 127, 123, 173, 78, 121, 174, 77, and 170) when: 1. The facility failed to assess for the risk of entrapment from side rails prior to use of side rails for 25 of 25 residents (Residents 122, 120, 175, 70, 73, 1, 79, 125, 72, 126, 71, 74, 76, 128, 171, 75, 172, 127, 123, 173, 78, 121, 174, 77, and 170). 2. The facility failed to review the risks and benefits of side rails with the resident or resident representatives (RP) and obtain informed consent (a process which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) prior to the use of side rails for 25 of 25 residents (Residents 122, 120, 175, 70, 73, 1, 79, 125, 72, 126, 71, 74, 76, 128, 171, 75, 172, 127, 123, 173, 78, 121, 174, 77, and 170). 3. The facility failed to attempt alternative measures prior to the use of side rails for 25 of 25 residents (Residents 122, 120, 175, 70, 73, 1, 79, 125, 72, 126, 71, 74, 76, 128, 171, 75, 172, 127, 123, 173, 78, 121, 174, 77, and 170). 4. The facility failed to ensure physician orders were obtained prior to the use of the side rails for 25 of 25 residents (Residents 122, 120, 175, 70, 73, 1, 79, 125, 72, 126, 71, 74, 76, 128, 171, 75, 172, 127, 123, 173, 78, 121, 174, 77, and 170). These failures had the potential to put all 25 residents at risk of entrapment and serious injury. FINDINGS: Review of the U.S Food and Drug Administration (FDA) Hospital Bed Safety Workgroup Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings, dated April 2003, indicated the FDA issued a Safety Alert entitled, "Entrapment Hazards with Hospital Bed Side Rails". This alert indicated "National surveys of patient deaths occurring in the bed environment demonstrate the risk of entrapment when a patient slips between the mattress and bed rail or when the patient becomes entrapped in the bed rail itself. The population at risk for entrapment are patients who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement... that cause them to move about the bed or try to exit from the bed." During an observation on 4/29/24 at 9 a.m., in the resident's room, Resident 120's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 9:10 a.m., in the resident's room, Resident 121's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 9:14 a.m., in the resident's room, Resident 175's bed had 4 side rails installed with the three side rails in the upright position. During an observation on 4/29/24 at 9:16 a.m., in the resident's room, Resident 122's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 9:24 a.m., in the resident's room, Resident 125's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 9:29 a.m., in the resident's room, Resident 126's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 9:37 a.m., in the resident's room, Resident 128's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 9:38 a.m.., in the resident's room, Resident 173's bed had 4 side rails installed with one upper side rail in the upright position. During an observation on 4/29/24 at 9:41 a.m., in the resident's room, Resident 127's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 9:50 a.m., in the resident's room, Resident 123's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 11:32 a.m., in the resident's room, Resident 170's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 2:54 p.m., in the resident's room, Resident 70's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 3:31 p.m., in the resident's room, Resident 71's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 3:31 p.m., in the resident's room, Resident 72's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 3:31 p.m., in the resident's room, Resident 73's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 3:31 p.m., in the resident's room, Resident 75's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 3:31 p.m., in the resident's room, Resident 76's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 3:33 p.m., in the resident's room, Resident 74's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 3:42 p.m., in the resident's room, Resident 79's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/30/24 at 9:22 a.m., in the resident's room, Resident 171's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/30/24 at 9:22 a.m., in the resident's room, Resident 174's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/30/24 at 9:22 a.m., in the resident's room, Resident 172's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/30/24 at 10:23 a.m., in the resident's room, Resident 1's bed had 4 side rails installed with the two upper side rails in the upright position. During a concurrent interview and record review on 4/30/24 at 10:53 a.m., with Registered Nurse (RN) B, RN B reviewed the electronic records of some residents, then RN B stated that all residents were assessed and informed about the use of side rails but there was no documentation about the risk and benefits for the use of side rails given to all residents. RN B further stated there was no need for physician orders for the use of side rails unless if it was used as a restraint. RN B also stated there was no alternatives to the use of side rails discussed with any of the residents and their responsible parties. During a concurrent interview and record review on 4/30/24 at 1:21 p.m., with RN C, RN C reviewed all the 25 residents' electronic records and stated that all the residents must always have the side rails in the upright position. RN C stated that no alternatives were used because every patient (meant Resident) must have the two side rails up. RN C further stated the use of side rails does not need to have a consent and physician orders. RN C also stated that residents were assessed and informed of the risk and benefits of the use of side rails verbally but there was no documentation done. RN C also stated there was no policy for the use of side rails. During an observation on 5/1/24 at 2:55 p.m., in the resident's room, Resident 77's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 5/1/24 at 2:57 p.m., in the resident's room, Resident 78's bed had 4 side rails installed with the two upper side rails in the upright position. During an interview on 05/02/24 at 1:10 p.m., with the Director of Nursing (DON), the DON stated there was no alternatives for the use of side rails. The DON stated consent and physician order were not required because the use of side rails was an intervention used to prevent falls. The DON stated that assessment was done for the prevention of falls and not for the use of side rails. The DON also stated they have no side rails policy. This violation had a direct or immediate relationship to the health, safety, or security of the residents.