Health inspection·October 10, 2024

Children's Health Organization Northern California Saratoga Pediatric Sub Acute Recertification Survey Event ID 8E1Y11 Exit Date 7/23/24 State Citation B was written. 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. From 7/15/24 to 7/23/24, an unannounced recertification survey and extended survey was conducted at the facility. The facility failed to follow their "Bed/Side Rails" policy for 20 of 22 patients (1, 2, 3, 4, 5, 6, 9, 11, 14, 16, 18, 23, 24, 25, 27, 181, 182, 184, 330, and 331) when they did not attempt alternative measures prior to applying bed side rails. This failure had the potential to place the patients at risk of entrapment and serious injury. During an observation in Patient 11's room on 7/15/24, at 10:19 a.m., Patient 11 was in bed with side rails up. Review of Patient 11's physician order, dated 2/7/23, indicated she had an order for "Upper Side Rails." Review of Patient 11's Postural Support/Developmental Safety Device Rationale and Consent, dated 12/19/23, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Patient 1's room on 7/15/24, at 10:20 a.m., Patient 1 was in bed with left side rail up. Review of Patient 1's physician order, dated 7/12/23, indicated she had an order for "Left Side Rail." Review of Patient 1's Postural Support/Developmental Safety Device Rationale and Consent, dated 1/9/23, indicated alternative measures were not attempted prior to the use of side rail. During an observation in Patient 2's room on 7/15/24, at 10:22 a.m., Patient 2 was in bed with side rails up. Review of Patient 2's physician order, dated 11/29/21, indicated he had an order for "Side Rails." Review of Patient 2's Postural Support/Developmental Safety Device Rationale and Consent, dated 12/20/23, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Patient 181's room on 7/15/24, at 10:25 a.m., Patient 181 was in bed with side rails up. Review of Patient 181's physician order, dated 2/16/24, indicated he had an order for "Full Side Rails." Review of Patient 181's Postural Support/Developmental Safety Device Rationale and Consent, dated 3/22/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Patient 25's room on 7/15/24, at 10:27 a.m., Patient 25 was in bed with side rails up. Review of Patient 25's physician order, dated 10/18//23, indicated she had an order for "Upper Side Rails." Review of Patient 25's Postural Support/Developmental Safety Device Rationale and Consent, dated 1/17/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Patient 16's room on 7/15/24, at 10:28 a.m., Patient 16 was in bed with side rails up. Review of Patient 16's physician order, dated 2/15/23, indicated she had an order for "Upper Side Rails." Review of Patient 16's Postural Support/Developmental Safety Device Rationale and Consent, dated 3/27/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Patient 5's room on 7/15/24, at 10:29 a.m., Patient 5 was in bed with side rails up. Review of Patient 5's physician order, dated 2/15/23, indicated she had an order for "Left Right Side Rails." Review of Patient 5's Postural Support/Developmental Safety Device Rationale and Consent, dated 4/9/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Patient 182's room on 7/15/24, at 11:19 a.m., Patient 182 was in bed with side rails up. Review of Patient 182's physician order, dated 11/10/23, indicated he had an order for "Full Side Rails." Review of Patient 182's Postural Support/Developmental Safety Device Rationale and Consent, dated 11/7/23, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Patient 3's room on 7/15/24, at 11:31 a.m., Patient 3 was in bed with side rails up. Review of Patient 3's physician order, dated 5/23/24, indicated she had an order for "All Side Rails." Review of Patient 3's Postural Support/Developmental Safety Device Rationale and Consent, dated 5/17/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Patient 330's room on 7/15/24, at 12:11 p.m., Patient 330 was in bed with bilateral (both sides) upper side rails and one lower siderail up. Review of Patient 330's physician order, dated 12/12/23, indicated he had an order for "Upper Side Rails." Review of Patient 330's Postural Support/Developmental Safety Device Rationale and Consent, dated 12/12/23, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Patient 4's room on 7/15/24, at 12:11 p.m., Patient 4 was in bed with one upper and one lower side rails up. Review of Patient 4's physician order, dated 2/17/23, indicated he had an order for "Upper Side Rails." Review of Patient 4's Postural Support/Developmental Safety Device Rationale and Consent, dated 12/14/23, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Patient 24's room on 7/15/24, at 12:12 p.m., Patient 24 was in bed with bilateral upper and lower side rails up. Review of Patient 24's physician order, dated 2/27/24, indicated he had an order for "Upper Side Rails." Review of Patient 24's Postural Support/Developmental Safety Device Rationale and Consent, dated 2/28/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Patient 27's room on 7/15/24, at 12:12 p.m., Patient 27 was in bed with bilateral upper side rails and one lower side rail up. Review of Patient 27's physician order, dated 1/30/24, indicated he had an order for "Full Side Rails." Review of Patient 27's Postural Support/Developmental Safety Device Rationale and Consent, dated 3/22/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Patient 9's room on 7/15/24, at 12:13 p.m., Patient 9 was in bed with bilateral upper side rails up. Review of Patient 9's physician order, dated 11/14/23, indicated she had an order for "Side Rails." Review of Patient 9's Postural Support/Developmental Safety Device Rationale and Consent, dated 5/23/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Patient 14's room on 7/15/24, at 12:27 p.m., Patient 14 was in bed with bilateral upper and lower side rails up. Review of Patient 14's physician order, dated 2/13/23, indicated she had an order for "Full Side Rails." Review of Patient 14's Postural Support/Developmental Safety Device Rationale and Consent, dated 5/23/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Patient 6's room on 7/16/24, at 8:15 a.m., Patient 6 was in bed with bilateral upper side rails up. Review of Patient 6's physician order, dated 10/11/19, indicated she had an order for "Side Rails." Review of Patient 6's Postural Support/Developmental Safety Device Rationale and Consent, dated 5/17/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Patient 331's room on 7/16/24, at 8:33 a.m., Patient 331 was in bed with bilateral upper and lower side rails up. Review of Patient 331's physician orders indicated there was no order for the use of side rails. Review of Patient 331's Postural Support/Developmental Safety Device Rationale and Consent, dated 8/25/23, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Patient 18's room on 7/16/24, at 8:33 a.m., Patient 18 was in bed with bilateral upper and lower side rails up. Review of Patient 18's physician order, dated 2/15/23, indicated he had an order for "Upper and Lower Side Rails." Review of Patient 18's Postural Support/Developmental Safety Device Rationale and Consent, dated 12/14/23, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Patient 184's room on 7/17/24, at 11:25 a.m., Patient 184 was in bed with side rails up. Review of Patient 184's physician order, dated 7/16/24, indicated he had an order for "Upper Side Rails." Review of Patient 184's Postural Support/Developmental Safety Device Rationale and Consent, dated 7/8/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Patient 23's room on 7/17/24, at 11:32 a.m., Patient 23 was in bed with side rails up. Review of Patient 23's physician order, dated 7/16/24, indicated she had an order for "Upper Side Rails." Review of Patient 23's Postural Support/Developmental Safety Device Rationale and Consent, dated 7/11/24, indicated alternative measures were not attempted prior to the use of side rails. During an interview with the rehabilitation supervisor (RS) on 7/22/24, at 11:33 a.m., she stated the alternative measures such as frequent visual check for safety, pillow/wedged cushions, or frequent repositioning, etc. would be attempted only if the responsible party (the party responsible to making health care decisions when the principal party is unable to make health care decisions for him or herself) of the patient refused to give the consent for side rail. Otherwise, the side rail would be used. The RS acknowledged that the alternative measures should be attempted prior to the use of side rail. During an interview with the director of nursing (DON) on 7/22/24, at 11:36 a.m., she confirmed alternative measures were not attempted for Patients 1, 2, 3, 4, 5, 6, 9, 11, 14, 16, 18, 23, 24, 25, 27, 181, 182, 184, 330, and 331 prior to the use of side rail. Review of the facility's undated policy, "Bed/Side Rails," indicated "... 4. Appropriate alternative interventions are to be utilized prior to using bed/side rails..." In violation of the above cited standards, the facility failed to ensure proper use of side rails. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients.