Other·June 14, 2024

O'Connor Hospital D/P - SNF Exit Date: 5/20/24 The following reflects the findings of the California Department of Public Health during a recertification survey. Event ID H3MW11 Representing the Department, HFEN # 46001 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 5/13/2024, an unannounced visit was conducted at the facility for a recertification survey. The facility failed to ensure proper use of side rails (or bed rails, adjustable rigid bars attached to the side of a bed [examples include safety rails, grab bars, and assist bars]) for 23 of 23 residents (Residents 1, 14, 21, 15, 10, 13, 11, 2, 7, 3, 22, 8, 19, 5, 9, 4, 6, 12, 16, 17, 18, 20, and 23), when 1. For Residents 4 and 23, the Siderail Assessment indicated side rails were not required, though the residents were observed to have side rails. 2. The facility failed to offer/or attempt alternatives prior to the use of side rails and no documentation indicated alternatives were offered and/or attempted prior to using side rails for 23 of 23 residents with side rails (Residents 1, 14, 21, 15, 10, 13, 11, 2, 7, 3, 22, 8, 19, 5, 9, 4, 6, 12, 16, 17, 18, 20, and 23). These failures had the potential to place all 23 residents at risk of entrapment and serious injury. 1. During an observation in Resident 4's room on 5/13/24 at 11:00 a.m., Resident 4 was lying in bed with both upper side rails in the upright position. During an observation in Resident 23's room on 5/13/24 at 11:35 a.m., Resident 23 was lying in bed with both upper side rails in the upright position. A record review of Resident 4's 'Siderail Assessment' dated 4/2/2024, indicated "8. The Resident has a medical justification for use of siderails? No; Siderail Consent Form obtained? No; Siderail x2 Order Placed? Yes.... The Assessment has determined the use of siderails is indication reason: Not indicated." A record review of Resident 23's "Siderail Assessment" dated 4/25/2024, indicated "8. The Resident has a medical justification for use of siderails? No, ... The assessment has determined the use of siderails is: Not indicated." During a concurrent interview and record review with Licensed Vocational Nurse (LVN) B on 5/16/24 at 11:15 a.m., LVN B reviewed Resident 4's Siderail Assessment dated 4/2/2024 and confirmed there was no indication to use the side rails. During a concurrent interview and record review with LVN B on 5/16/2024 at 11:17 a.m., LVN B reviewed Resident 23's Siderail Assessment dated on 4/25/2024 and confirmed there was no indication to use the side rails. During an interview with the Clinical Manager (CM) on 5/20/24 at 11:04 a.m., the CM confirmed that Resident 4 and 23's side rail assessment did not require them to have side rails and using side rails might place the residents at risk of entrapment and serious injury. 2. During an observation on 5/13/24 at 8:45 a.m., in the resident's room, Resident 1's bed had four side rails installed with the two upper side rails in the upright position. During an observation on 5/13/24 at 8:56 a.m., in the resident's room, Resident 14's bed had four side rails installed with the two upper side rails in the upright position. During an observation on 5/13/24 at 8:55 a.m., in the resident's room, Resident 21's bed had four side rails installed with the two upper side rails in the upright position. During an observation on 5/13/24 at 8:57 a.m., in the resident's room, Resident 15's bed had four side rails installed with the two upper side rails in the upright position. During an observation on 5/13/24 at 8:59 a.m., in the resident's room, Resident 10's bed had four side rails installed with the two upper side rails in the upright position. During an observation on 5/13/24 at 9:04 a.m., in the resident's room, Resident 13's bed had four side rails installed with the two upper side rails in the upright position. During an observation on 5/13/24 at 9:32 a.m., in the resident's room, Resident 11's bed had four side rails installed with the two upper side rails in the upright position. During an observation on 5/13/24 at 12:22 p.m., in the resident's room, Resident 2's bed had four side rails installed with the two upper side rails in the upright position. During an observation on 5/13/24 at 08:45 a.m. in Resident 7's room, Resident 7 was lying in bed with both upper siderails in upright position. During an observation on 5/13/24 at 9:00 a.m. in Resident 3's room, Resident 3 had both upper siderails in upright position. During an observation on 5/13/24 at 10:40 a.m. in Resident 22's room, Resident 22 was awake, seated up in bed with both upper siderails in upright position. During an observation on 5/13/24 at 12:46 p.m. in Resident 8's room, Resident 8 was lying in bed with both upper siderails in upright position. During an observation on 5/13/24 at 12:48 p.m. in Resident 19's room, Resident 19 was lying in bed with both upper siderails in upright position. During an observation on 5/13/24 at 12:54 p.m. in Resident 5's room, Resident 5 was lying in bed with both upper siderails in upright position. During an observation on 5/13/24 at 12:56 p.m. in Resident 9's room, Resident 9 was lying in bed with both upper siderails in upright position. During an observation in Resident 4's room on 5/13/24 at 11:00 a.m., Resident 4 was lying in bed with both upper side rails in the upright position. During an observation in Resident 6 's room on 5/13/24 at 11:10 a.m., Resident 6 was lying in bed with both upper side rails in the upright position. During an observation in Resident 12 's room on 5/13/24 at 11:15 a.m., Resident 12 was lying in bed with both upper side rails in the upright position. During an observation in Resident 16 's room on 5/13/24 at 11:20 a.m., Resident 16 was lying in bed with both upper side rails in the upright position. During an observation in Resident 17 's room on 5/13/24 t 11:23 a.m., Resident 17 was lying in bed with both upper side rails in the upright position. During an observation in Resident 18 's room on 5/13/24 at 11:25 a.m., Resident 18 was lying in bed with both upper side rails in the upright position. During an observation in Resident 20 's room on 5/13/24 at 11:30 a.m., Resident 20 was lying in bed with both upper side rails in the upright position. During an observation in Resident 23 's room on 5/13/24 at 11:35 a.m., Resident 23 was lying in bed with both upper side rails in the upright position. During an interview with Registered Nurse (RN) C on 5/15/2024 at 10:08 a.m., RN C confirmed that 23 residents (Resident 1, 14, 21, 15, 10, 13, 11, 2, 7, 3, 22, 8, 19, 5, 9, 4, 6, 12, 16, 17, 18, 20, and 23) were using bilateral upper-side rails and stated all the upper-side rails were installed before admission, and further stated no alternatives were provided to the residents prior to using them. During an interview review with the Director of Operations (DO) on 5/15/24 at 4:00 p.m., the DO stated that they did not offer alternatives to use before installing the siderails. During an interview with the CM on 5/20/2024 at 11:04 a.m., the CM confirmed that 23 residents (Residents 1, 14, 21, 15, 10, 13, 11, 2, 7, 3, 22, 8, 19, 5, 9, 4, 6, 12, 16, 17, 18, 20, and 23) were using bilateral upper-side rails, no alternatives were provided or attempted prior to installing the side rails and no documentation indicated that the alternatives were provided. During a review of the facility's policy and procedure (P&P) titled "Side Rails", the P&P indicated "To provide a resident with safety devices for medical conditions, or as a restraining devise to prevent injuries for those residents who have been assessed for the use of restraints and for whom the use of side rails has been determined to be the appropriate, least restrictive type of restraint and informed consent from the physician has been obtained for their use...upon admission to the facility, all residents will be assessed to determine if the use of side rails is justified, in accordance with the Side Rail Assessment Policy and Procedure..." This violation had a direct or immediate relationship to the health, safety, or security of the residents. EID H3MW11 OCH D/P-SNF