Health inspection·December 10, 2020

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. 3. On 12/7/20 at 11:49 a.m., Resident #98 was observed in bed with bed rails raised on the upper half of both sides of the bed. Resident #98 was pleasantly confused. He said he didn't know anything about the bed rails and that he did not use them. On 12/8/20 at 9:26 a.m., Resident #98 was observed in bed with two bed rails raised and one rail extended to middle of the bed. On 12/8/20 9:27 a.m., during an interview Unit Manager (UM)/ Licensed Practical Nurse (LPN) Staff A stated Resident #98 was ambulatory and could toilet himself. UM/LPN Staff A said Resident #98 was confused. Record review showed there was no assessment for the use of bed rails. A quarterly evaluation dated 11/17/20 documented that no bed rails were in use. Resident #98's medical diagnosis included unspecified dementia. On 12/9/20 at 12:00 p.m., during an interview UM/LPN Staff A said she kept a log of all residents using bed rails. She stated this was updated on admission or if the family or resident requested. UM/LPN Staff A said the process of placing bed rails was the explanation of the benefits and risks, and obtaining consent. UM/LPN Staff A said these were not offered and only placed if the family or resident asked. UM/LPN Staff A said that prior to placement, alternatives were attempted, such as mats or low beds. UM/LPN Staff A said that Resident #98 did not have bed rails. On 12/9/20 at 12:03 p.m., Resident #98's bed was observed with UM/LPN Staff A, and she verified two bed rails were in place. UM/LPN Staff A said she believed his bed was changed out over the weekend due to a maintenance issue. On 12/9/20 at 12:07 p.m., during an interview UM/LPN Staff A said she evaluated for entrapment zones and maintenance did routine bed safety checks. She acknowledged several unused resident beds with bed rails present. UM/LPN Staff A said if rails were on an unused bed, there was a likelihood they could be used inadvertently. She said she would have maintenance remove the bed rails. Based on observation, record review, and interview, the facility failed to ensure 3 (Resident #98, #262 and #360) of 4 residents reviewed for accident hazards were assessed for the need for bed rails, obtained an informed consent prior to the use of the bed rails, and ensured evaluation for potential entrapment zones. Failure to ensure bed rails were appropriate and safe placed the residents at risk. Page 1 of 3 105462 105462 12/10/2020 Vivo Healthcare Clewiston 301 South Gloria St Clewiston, FL 33440

F 0700 The findings included: Level of Harm - Minimal harm or potential for actual harm The facility's Policies Statement, Subject: Bed Safety (effective December 2007) stated the facility Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, proper distance from the headboard and footboard, etc.); and Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness etc.). It further listed: Residents Affected - Few 1.The staff shall obtain consent for use of side rails from the resident or the resident's legal representative prior to their use. 2. Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails. 3. After appropriate review and consent as specified above, side rails may be used at the resident's sense of security (e.g., if he/she has fear of falling, his/her movement is compromised, or he/she is used to sleeping in a larger bed). 4. Side rails may be used if assessment and consultation with the Attending Physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in the bed and transfer, and no other reasonable alternatives can be identified. The Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment for industry and Food and Drug Administration (FDA) staff, issued on March 2006, identified the area between the bed rails and mattress and between the head or foot board and mattress as a risk for head entrapment. Recommendations included caution should be taken when using these products to ensure a tight fit of the mattress to the bed system. (source: https://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/UCM072729.pdf) 1. On 12/7/20 at 10:45 a.m., Resident #360 was observed seated in a bedside chair. The resident was friendly, confused. The resident's bed was observed with half bed rails installed on the center sides of the bed. The bed rail on the right side was positioned down. The left side bed rail was positioned up leaning into the bed. Resident #360 said the bed rails were on the bed when he was admitted . Resident #360's VHC Nursing Comprehensive Evaluation V3 form, dated 12/1/20 revealed, side rails are NOT in use OR required at this time. There was no order or consent in Resident #360's chart for the use of bed rails. On 12/9/20 at 11:40 a.m., during an interview with Licensed Practical Nurse (LPN) Staff B she said she was aware the resident's bed had side rails and said she did not pay attention if he had an order for the bed rails. She said the bed rails could have been left on the bed from the previous resident. She verified Resident #360 was not assessed for bed rails and had not signed a consent to use the bed rails. She said she would call maintenance to remove the bed rails. On 12/9/20 at 1:15 p.m., during an interview with the Assistant Maintenance Director (AMD) Staff D he said the bed rail was not correctly tightened to the bedframe. 105462 Page 2 of 3 105462 12/10/2020 Vivo Healthcare Clewiston 301 South Gloria St Clewiston, FL 33440

F 0700 Level of Harm - Minimal harm or potential for actual harm 2. On 12/9/20 at 1:45 p.m., during a tour with the AMD Staff D of the resident rooms with bed rails installed on the beds an observation was made of Resident #262 sitting in her room. Her bed had quarter bed rails installed on the upper half of the bed. The bed rail on the left was positioned down and the right bed rail was up. Resident #262 was alert and oriented and said she did not know why she had the bed rails on her bed. Resident # 262 said the bed rails get in her way. Residents Affected - Few On 12/9/20 at 1:50 p.m., during an interview with LPN Staff E, she said Resident #262 did not have an order for bed rails and instructed AMD Staff D to remove the bed rails. On 12/9/20 at 1/05 p.m., during an interview AMD Staff D said there were several models of beds and bed rails in the facility. He said some of the beds were compatible only with the bed rail that comes with the bed. He said he had the manufacture's manual for the 50 newer beds in the 155-bed facility. He said for the remaining beds, he did not have the manufacture's manual that provided information about each bed model for their bed rail compatibility. Additionally, he said he did a monthly bed inspection for all beds in the facility. He said each Friday the Unit Managers gave him a list of beds with bed rails and he inspected them that day. 105462 Page 3 of 3