Health inspection·April 5, 2024

The following reflects the findings of the California Department of Public Health during the Hazel Hawkins Memorial Hospital D/P SNF Re-certification Survey, Event ID: 3OI911. Representing the California Department of Public Health: 44185, Health Facilities Evaluator Nurse; 46001, Health Facilities Evaluator Nurse; 46552, Health Facilities Evaluator Nurse; and 48935, 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. From 3/11/24 to 3/19/24, an unannounced recertification survey and extended survey was conducted at the facility. The facility failed ensure proper use of bed rails (side rails, safety rails, and grab/assist bars) for 86 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 287, 387, 388, 389, and 390) when: 1. There was no documentation that the facility obtained informed consent (documentation that the resident/resident's responsible party and the facility are in agreement for certain items or services made available to the Resident, after the resident/resident's responsible party are educated on the item/service) prior to using bed rails. 2. There was no documentation that risks and benefits were explained to the residents or responsible parties (RP, individuals designated to make decisions on behalf of the residents) prior to using bed rails, 3. There was no documentation that the facility assessed for risk of entrapment (becoming trapped between the bed rail and mattress) prior to using bed rails, and 4. There was no documentation that alternatives were attempted prior to using bed rails. These failures had the potential to place the residents at risk of entrapment and serious injury. During an interview with Registered Nurse (RN) N on 3/12/224 at 11:45 a.m., RN N stated she was the admission nurse, and all residents had a standing order for "upper half rails up when in bed for bed mobility" to use the upper side rails upon admission. During an interview with Certified Nursing Assistant (CNA) O on 3/13/2024 at 8:50 a.m., CNA O stated that all Northside Skilled Nursing Facility (SNF) residents were using the upper half bedside rails. During an observation and interview with CNA P on 3/13/24 at 9:34 p.m., the beds of Residents 33, 10, 29, 287, 8, 35, and 6 were inspected. All seven beds had partial side rails (part of a whole, [full side rails are attached to the side of a bed along the full or whole length of the bed]) bilaterally (on both sides). CNA P confirmed the above observation and stated all the upper half bedside rails were set up for those residents. A review of Resident 33's face sheet (summary of a resident's important information) indicated Resident 33 was admitted to the facility on 8/30/2018. A review of Resident 33's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent, or assessed for risk of entrapment prior to using the bedside rails upon admission on 8/30/2018. A review of Resident 10's face sheet indicated Resident 10 was admitted to the facility on 9/11/2023. A review of Resident 10's clinical records indicated that there was no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent, or assessed for risk of entrapment prior to using the bedside rails upon admission on 9/11/2023. A review of Resident 29's face sheet indicated Resident 29 was admitted to the facility on 9/11/2023. A review of Resident 29's clinical records indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent, or assessed for risk of entrapment prior to using the bedside rails upon admission on 9/11/2023. A review of Resident 287's face sheet indicated Resident 287 was admitted to the facility on 2/28/2024. A review of Resident 287's clinical records indicated there was no documentation that the facility attempted alternatives or assessed for risk of entrapment prior to using the bedside rails upon admission on 2/28/2024. A review of Resident 8's face sheet indicated Resident 8 was admitted to the facility on 9/20/2023. A review of Resident 8's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent, or assessed for risk of entrapment prior to using the bedside rails upon admission on 9/20/2023. A review of Resident 35's face sheet indicated Resident 35 was admitted to the facility on 9/11/2018. A review of Resident 35's clinical records indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent, or assessed for risk of entrapment prior to using the bedside rails upon admission on 9/11/2018. A review of Resident 6's face sheet indicated Resident 6 was admitted to the facility on 8/30/2018. A review of Resident 6's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent, or assessed for risk of entrapment prior to using the bedside rails upon admission on 8/30/2018. During an interview with RN N on 3/18/2024 at 11:24 a.m., RN N stated that she was an admission nurse and did not assess for risk of entrapment, attempt alternatives, explain risks and benefits, or obtain informed consent before setting up the bedside rails upon admission. She confirmed that no documentation indicated that the facility attempted alternatives, explained risks and benefits, obtained informed consent, or assessed for risk of entrapment prior to using the bedside rails upon admission for Northside SNF residents, including Residents 33, 10, 29, 287, 8, 35, 6, 38, 57, 40, 52, 55, 46, 71, 44, 63, 21, 75, 5, 12, 31, 24, and 9. During an interview with the Director of Nursing (DON) on 3/18/2024 at 11:45 a.m., the DON confirmed that no documentation indicated that the facility attempted alternatives, explained risks and benefits, obtained informed consent, or assessed for risk of entrapment prior to using the bedside rails upon admission for all the residents. The DON stated that the interdisciplinary team (IDT) did some assessment but not prior to using the bedside rails. The DON further stated that staff started explaining the risks and benefits of using the bedside rails and obtaining informed consent since January 2024. A review of the facility's policy and procedure (P&P) titled "Side Rail" indicated "all beds are equipped permanently mounted Safety Side Rails. When ordered, these should be kept in a raised position at all times, except when a staff member is at the bedside giving nursing care..." During an interview with the DON on 3/19/2024 at 9:49 a.m., the DON stated that the Side Rail P&P needed to be revised to require that the facility attempt alternatives, explain risks and benefits, obtain informed consent, and assess for risk of entrapment prior to residents using the bedside rails upon admission. During an observation on 3/11/24 at 9:35 a.m., Resident 81's four half side rails were up. Review of Resident 81's face sheet indicated, Resident 81 was admitted to the facility on 6/3/23. A review of Resident 81's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to the facility. During an observation of Resident 51 in her room on 3/11/24 at 9:40 a.m., her bed's two half side rails were up. Review of Resident 51's face sheet indicated, Resident 51 was admitted to the facility on 1/21/19. Review of Resident 51's physician order, dated 3/6/19, indicated, Resident 51 had an order for upper half side-rails up when in bed for bed mobility. A review of Resident 51's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails, or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation of Resident 1's room on 3/11/24 at 9:42 a.m., Resident 1's bed's two half side rails were up. Review of Resident 1's face sheet indicated, Resident 1 was readmitted to the facility on 5/15/19. A review of Resident 1's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails, or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation of Resident 72's room on 3/11/24 at 9:45 a.m., Resident 72's bed with two 1/4 side rails were up. Review of Resident 72's face sheet indicated, Resident 72 was admitted to the facility on 7/21/22. A review of Resident 72's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation in the room of Resident 66 on 3/11/24 at 9:50 a.m., two half side rails were up for Resident 66's bed. Review of the face sheet of Resident 66 indicated, Resident 66 was admitted to the facility on 10/23/20. A review of Resident 66's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation of Resident 67's room on 3/11/24 at 9:52 a.m., one half side rail was up for Resident 67's bed. Review of Resident 67's face sheet indicated, Resident 67 was admitted to the facility on 10/26/21. A review of Resident 67's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for using side rails and assessed for risk of entrapment prior to using the bedside rails upon admission to the facility. During an observation of Resident 36 in his room on 3/11/24 at 9:55 a.m., three half side rails were up for Resident 36's bed. Review of Resident 36's face sheet indicated, Resident 36 was admitted to the facility on 7/27/23. A review of Resident 36's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation of Resident 3 in her room on 3/11/24 at 11:00 a.m., two 1/4 side rails were up for Resident 3's bed. Review of Resident 3's face sheet indicated, Resident 3 was admitted to the facility on 2/8/22. A review of Resident 3's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation of Resident 42 in his room on 3/11/24 at 11:35 a.m., two half side rails were up for Resident 42's bed. Review of Resident 42's face sheet indicated, Resident 42 was admitted to the facility on 3/9/22. A review of Resident 42's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation of Resident 11's room on 3/13/24 at 10:30 a.m., two half side rails were up for Resident 11's bed. Review of Resident 11's face sheet indicated, Resident 11 was admitted to the facility on 3/22/2008. A review of Resident 11's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation of Resident 80 in his room on 3/11/24 at 11:43 a.m., one 1/4 side rail was up for Resident 80's bed. Review of Resident 80's face sheet indicated, Resident 80 was admitted to the facility on 4/13/23. A review of Resident 80's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation of Resident 73 in his room on 3/11/24 at 11:47 a.m., Resident 73's bed was had two upper half side rails, plus one 1/4 side rail at foot of the bed, up. Review of Resident 73's face sheet indicated, Resident 73 was admitted to the facility on 8/23/22. A review of Resident 73's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation of Resident 61 in his room on 3/11/24 at 11:50 a.m., Resident 61's bed had two upper 1/4 side rails up. Review of Resident 61's face sheet indicated, Resident 61 was admitted to the facility on 5/24/21. A review of Resident 61's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation of Resident 47 in his room on 3/11/24 at 11:55 a.m., Resident 47's bed had upper two half side rails up. Review of Resident 47's face sheet indicated, Resident 47 was admitted to the facility on 1/25/23. Review of Resident 47's physician order, with the order date of 1/25/23 indicated, Resident 47 had an order for upper half side-rails up when in bed for bed mobility. A review of Resident 47's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation of Resident 60 in his room on 3/11/24 at 12:00 p.m., Resident 60's bed was with two half upper side rails were up. Review of Resident 60's face sheet indicated, Resident 60 was readmitted to the facility on 6/13/22. A review of Resident 60's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation of Resident 43 in his room on 3/11/24 at 12:02 p.m., Resident 43's bed was with two half upper side rails were up. Review of Resident 43's face sheet indicated, Resident 43 was admitted to the facility on 8/24/22. A review of Resident 43's