Other·June 30, 2021

The following reflects the findings of the California Department of Public Health during the investigation of: Entity Reported Incident # CA00736504 Event ID: YG4C11 Representing the Department, HFEN # 37686 State Citation B was written F604, §483.10(e)(1); §483.12(a)(2) Right to be Free from Physical Restraints §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). §483.12(a)(2) The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. , and not required to treat the resident's medical that the resident is free from physical or chemical restraints imposed f On 5/14/2021, an unannounced visit was conducted at the facility to investigate an entity reported incident regarding Quality of Care/Treatment. The facility failed to ensure Resident 1 was free from physical restraints when Resident 1’s wrist was wrapped to his side rail with a pillowcase. This failure had the potential to compromise the resident’s physical and psychosocial well-being. Review of Resident 1’s clinical record indicated he had the diagnoses of anoxic brain damage (brain damage caused by lack of oxygen), psychosis (severe mental disorder) and contracture (condition that causes joints to become very stiff). Review of Resident 1’s Minimum Data Set (MDS, an assessment tool), dated 4/6/2021, indicated he had severe cognitive impairment, impaired range of motion (the full movement potential of a joint) in both upper and lower extremities (both arms and both legs), and required total assistance (full staff performance) for all activities of daily living (self-care activities such as bed mobility, transfers, eating, dressing, grooming and bathing). Review of the facility’s Report of Suspected Dependent Adult/Elder Abuse, dated 5/13/2021, indicated staff reported that Resident 1’s right wrist was entangled with a pillowcase. During an interview with the director of nursing (DON) on 5/14/2021 at 11:39 a.m., he stated certified nursing assistant A (CNA A) and CNA B were the ones who saw Resident 1’s right wrist entangled with a pillowcase. He stated licensed vocational nurse C (LVN C) was Resident 1’s nurse during the incident. The DON explained Resident 1 was normally able to move his right arm, but had functional impairment of his left arm. During an interview with CNA A on 5/14/2021 at 1:05 p.m., she explained that she and CNA B were providing care for Resident 1 when they noticed the pillowcase around his wrist. CNA A stated part of the pillowcase was coiled around Resident 1’s wrist, and the other part was coiled around Resident 1’s side rail. During an interview with CNA B on 6/1/2021 at 1:45 p.m., she stated when she and CNA A were providing care for Resident 1, his right wrist was tied to the side rail with a pillowcase. CNA B explained that one end of the pillowcase was coiled around Resident 1’s wrist, and the other end of the pillowcase was tied in a knot on Resident 1’s side rail. During an interview with LVN C on 6/22/2021 at 3:40 p.m., she stated she did not see Resident 1’s wrist tied or wrapped to the side rail. LVN C acknowledged that tying the resident’s wrist to the side rail was considered a restraint. Review of Resident 1’s Physical Restraint Assessment, dated 3/29/2021, indicated physical restraints were not recommended. Further review of Resident 1’s clinical record indicated he did not have a consent, physician’s order, or a care plan for application of restraints. During an interview with the DON on 6/23/2021 at 1:30 p.m., he confirmed that restraints were not part of Resident 1’s care plan. He also confirmed Resident 1 did not have a consent or physician’s order for application of restraints. Review of the facility’s policy titled “Use of Restraints,” revised 8/2007 indicated, “Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident’s body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one’s body.” “Restraints shall only be used to treat the resident’s medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls.” The policy further indicated, “Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor).” In violation of the above cited standards, the facility failed to ensure Resident 1 was free from physical restraints when Resident 1’s wrist was wrapped to his side rail with a pillowcase. This failure had the potential to compromise the resident’s physical and psychosocial well-being. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to the resident.