Other·May 17, 2024

The following reflects the findings of the California Department of Public Health during the Katherine Healthcare Center Recertification Survey, Event ID: GHAS11. Representing the California Department of Public Health: 37409, Health Facilities Evaluator Nurse; 44583, Health Facilities Evaluator Nurse; and, 46553, Health Facilities Evaluator Nurse. A Class "B" Citation was written for the following violation: 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)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails. From 4/22/24 to 4/30/24, an unannounced visit was conducted at the facility for a recertification survey. The facility failed to ensure proper use of bed rails (side rails, safety rails, and grab/assist bars) when 1. manufacturers' recommendations and specifications for installation and maintenance of the facility's beds and side rails (adjustable rigid bars attached to the side of a bed) were not followed; 2. alternatives to bedrails were not attempted; 3. assessments were not done for entrapment; 4. bed or side rail assessment forms were not updated; 5. a physician's order that would indicate the use of bed or side rails was not obtained for some to all of five residents (Residents 26, 145, 194, 17, and 4) who used bed or side rails. These failures had the potential to place the residents at risk of entrapment and serious injury. 1. There was no documentation that indicated the facility followed the manufacturers' recommendations and specifications for installation and maintenance of the facility's beds and side rails for five residents (Residents 26, 145, 194, 17, and 4). During a concurrent observation and interview on 4/22/2024 at 9:47 a.m., in Resident 26's room, Resident 26 had the bilateral (both sides) upper bed rails in upright position. Resident 26 stated she used her bed rails to transfer out of bed. During an observation on 4/22/2024 at 10:11 a.m., in Resident 145's room, Resident 145 had the left upper bed rail in upright position. During an observation on 4/22/2024 at 10:16 a.m., in Resident 194's room, Resident 194 was asleep on his bed and the right upper bed rail was observed in upright position. During an observation on 4/22/2024 at 11:51 a.m., in Resident 17's room, Resident 17 was in bed and had the bilateral upper bed rails in upright position. During an observation on 4/22/2024 at 2:54 p.m., in Resident 4's room, Resident 4 had the left upper bed rail in upright position. During a concurrent observation and interview with licensed vocational nurse A (LVN A) on 4/24/2024 at 11:05 a.m., in Resident 26's room, Resident 26 had the bilateral upper bed rails in upright position. LVN A confirmed the observation. During a concurrent observation and interview with LVN A on 4/24/2024 at 11:07 a.m., in Resident 194's room, Resident 194 had the right upper bed rail in upright position. LVN A confirmed the observation. During a concurrent observation and interview with LVN A on 4/24/2024 at 11:10 a.m., in Resident 17's room, Resident 17 had the bilateral upper bed rails in upright position. LVN A confirmed the observation. During an interview with maintenance supervisor (MS) on 4/24/2024 at 3:40 p.m., MS confirmed there should be no bed rails installed in bed for newly admitted residents (Resident 194). MS stated the nurses would call him when they needed him to install the bed rails on resident's bed. MS confirmed he would install the bed rails as instructed by nurses without following the manufacturers' specifications for bed installation. MS stated he did not have any documentation indicated that he followed the manufacturer's recommendations for safe use of bed rails. During an interview with director of nursing (DON) on 4/24/2024 at 4:14 p.m., DON confirmed their beds were old and they did not have the manufacturer's handbook anymore. Review of the facility's policy and procedure titled, "Proper Use of Side Rails," date revised 12/2016, indicated, "Manufacturer instructions for the operation of side rails will be adhered to. The resident will be checked periodically for safety relative to side rail use." 2. There was no documentation that indicated alternatives were offered and/or attempted prior to the use of bed or side rails for three residents (Residents 194, 17, and 4). During a concurrent interview and record review with minimum data set coordinator (MDSC, a licensed nurse in charge of resident assessment) on 4/24/2024 at 12:30 p.m., MDSC reviewed Resident 17's "Device Assessment Tool" for bed rail use dated 3/7/2024. MDS confirmed there was no documentation that indicated alternatives were offered or attempted prior to Resident 17's used of bilateral upper bed rails. During a concurrent interview and record review with DON on 4/24/2024 at 12:43 p.m., DON reviewed Resident 4's, "Device Assessment Tool" for bed rail use dated 8/19/2023. DON confirmed there was no documentation that indicated alternatives were offered or attempted prior to Resident 4's used of left upper bed rail. During a concurrent interview and record review with DON on 4/24/2024 at 12:49 p.m., DON reviewed Resident 194's "Bed Rail Observation/Assessment (INITIAL)," dated 4/22/2024. DON confirmed she completed Resident 194's assessment on 4/22/2024 at 11:37 a.m. DON was informed about the surveyor's above observation on 4/22/2024 at 10:16 a.m. when Resident 194 had the right upper bedrail already installed in his bed before the DON did the assessment and before they tried to attempt an alternative. DON confirmed there was no alternatives offered or attempted prior to Resident 194's used of right upper bed rail. During an interview with MS on 4/24/2024 at 3:40 p.m., MS stated Resident 194 was admitted to the facility on 4/21/2024. MS further stated the nurse called him on 4/21/2024 to install Resident 194's right bed rail. MS confirmed he came to the facility on 4/21/2024 and installed Resident 194's right bed rail as instructed. Review of the facility's policy and procedure titled, "Proper Use of Side Rails," date revised 12/2016, indicated, "Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails." 3. There was no documentation that indicated an entrapment risk assessment was completed prior to the use of bed or side rails for two residents (Residents 17, and 4). During a concurrent interview and record review with DON on 4/24/2024 at 12:35 p.m., DON reviewed Resident 17's "Device Assessment Tool" for bed rail use dated 3/7/2024. DON confirmed Resident 17 had no entrapment risk assessment completed prior to bed rail used. During a concurrent interview and record review with DON on 4/24/2024 at 12:43 p.m., DON reviewed Resident 4's "Device Assessment Tool" for bed rail use dated 8/19/2023. DON confirmed Resident 4 had no entrapment risk assessment completed prior to bed rail used. Review of the facility's policy and procedure titled, "Proper Use of Side Rails," date revised 12/2016, indicated, "An assessment will be made to determine the resident's symptoms, risk of entrapment..." 4. There was no updated bed or side rail assessment form completed for one resident (Resident 4). During an interview with DON on 4/24/2024 at 12:35 p.m., DON confirmed bed rail assessment should be completed upon admission, quarterly, and during significant change in resident's condition. DON stated the assessment should collaborate with minimum data set (MDS, an assessment tool) assessments (admission, quarterly, annual, and significant change in status assessment). During a concurrent interview and record review with DON on 4/24/2024 at 12:43 p.m., DON reviewed Resident 4's "Device Assessment Tool" for bed rail use dated 8/19/2023. DON confirmed although an initial Device Assessment Tool done on 8/19/2023 for Resident 4's bed rail use, it was not updated quarterly. Review of Resident 4's assessment form titled, "Device Assessment Tool V1.1 - V2 (version 1.1 - version 2)," dated 8/19/2023, indicated licensed nurses should complete each section of the assessment and it should be done initially, quarterly, annually, and during significant change. 5. There was no physician's order that indicated the use of bed or side rails for one resident (Resident 4). During a concurrent observation and interview with DON on 4/29/2024 at 9:52 a.m., in Resident 4's room, Resident 4 had the left upper bed rail in upright position. DON confirmed the observation and stated nurses should obtain a physician's order for bed rail use prior to installation of bed rails. Review of Resident 4's Order Summary Report, dated 4/3/2024, indicated Resident 4 did not have a physician's order for the bed rail used. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.