Other·October 11, 2022

REGULATION VIOLATION: 483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. 483.10(a)(l) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. 483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. 483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. 483.10(b)(l) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. 483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 72315. Nursing Service - Patient Care. (c) Each patient, upon admission, shall be given orientation to the skilled nursing facility and the facility's services and staff. (e) Each patient shall be encouraged and/or assisted to achieve and maintain the highest level of self-care and independence. Every effort shall be made to keep patients active, and out of bed for reasonable periods of time, except when contraindicated by orders of a licensed health care practitioner acting within the scope of his or her professional licensure. 72317. Nursing Service -Standing Orders. Standing orders shall not be used in skilled nursing facilities. 72319. Nursing Service - Restraints and Postural Supports. (a) Written policies and procedures concerning the use of restraints and postural supports shall be followed. (b) Restraints shall only be used with a written order of a licensed healthcare practitioner acting within the scope of his or her professional licensure. The order must specify the duration and circumstances under which the restraints are to be used. Orders must be specific to individual patients. In accordance with Section 72317, there shall be no standing orders and in accordance with Section 72319(i)(2)(A), there shall be no P.R.N. orders for physical restraints. (c) The only acceptable forms of physical restraints shall be cloth vests, soft ties, soft cloth mittens, seat belts and trays with spring release devices. Soft ties mean soft cloth which does not cause abrasion, and which does not restrict blood circulation. (d) Restraints of any type shall not be used as punishment, as a substitute for more effective medical and nursing care, or for the convenience of staff. (e) No restraints with locking devices shall be used or available for use in a skilled nursing facility. (i) (1) Treatment restraints may be used for the protection of the patient during treatment and diagnostic procedures such as, but not limited to, intravenous therapy or catheterization procedures. Treatment restraints shall be applied for no longer than the time required to complete the treatment. (i) (2) Physical restraints for behavior control shall only be used on the signed order of a physician, or unless the provisions of section 1180.4(e) of the Health and Safety Code apply to the patient, a psychologist, or other person lawfully authorized to prescribe care, except in an emergency which threatens to bring immediate injury to the patient or others. In such an emergency an order may be received by telephone and shall be signed within 5 days. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time and the name of the individual applying such measures shall be entered in the patient's health record. (i) (2) (B) Each patient care plan which includes the use of physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used and the time limit for the use of the method. 72515. Admission of Patients. The licensee shall: (b) Accept and retain only those patients for whom it can provide adequate care. On August 10, 2022, at 2:16 PM, an unannounced visit was conducted at the facility to investigate a complaint regarding shackles/restraints being used on Justice Involved Patients. Patient 1 was observed in bed, a shackle (locking metal device with a chain allowing patient to stand next to bed) had one end attached to bedrail on August 11, 2022, at 4:14 PM. Patient 2 was observed in bed with a shackle to left ankle attached to bedrail on August 10, 2022, at 2:16 PM. Patient 3 was observed in bed with a shackle to left ankle attached to bedrail on August 10, 2022, at 2:21 PM. Patient 4 was observed in bed with shackle to left ankle attached to bedrail on August 10, 2022, at 2:22 PM. Patient 5 was observed in bed, shackle end attached to bedrail on August 11, 2022, at 4:14 PM. These patients were observed to not be able to move freely around their room, or the facility or to participate freely is social interactions with other patients or participate in activities outside their room. The facility failed to: 1. Assess, monitor, and document skin integrity due to shackles/restraints. 2. Implement interventions prescribed in the care plan to include assessing skin integrity every two hours and as needed. 3. Include on restraint orders the rationale for the use of the restraint and the duration of the restraint. 4. Follow the facility's policies and procedures titled "Physical Restraint Application "and "Residents Rights." 5. Allow these five patients (Patients 1, 2, 3,4 and 5) to attend activities, participate freely in social interactions with other patients, to freely move around their room and the facility and to participate in activities outside of their room as allotted to the other (79) patients resideing in the facility. 1. Patient 1 was a 58-year-old female, admitted to the facility on July 07, 2022, with diagnoses which included: cirrhosis of liver (liver damage/failure usually related to alcoholism), moderate intellectual disabilities (delay in developmental milestones with intelligent quotient of 35-49), schizophrenia (thought disorder characterized by hallucinations and delusions), long term (Current) use of anticoagulants (blood thinners). During review on August 11, 2022, at 11:14 AM, of Patient 1's Physician's order dated July 07, 2022, at 6:49 PM, the order indicated, "Resident under the custody of California Department of Correction and Rehabilitation (CDCR, [name of State Hospital] Patients) is under jurisdiction of CDCR. CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape." (Exhibit A section S 2016 DSH- [name of State Hospital] contract) Patient is a risk for negative effects of use of shackle such as skin discoloration, impaired circulation, and skin break down." During review of Patient 1's medical records under "Nurses Progress Notes" on August 11, 2022, at 11:14AM, there was no documented evidence of restraint assessments, or skin assessments due to shackles/restraints having been done since Patient 1's admission on June 7, 2022, through August 11, 2022. Under the section for the MDS (Minimum Data Set- a computerized assessment tool), there was no documented evidence Patient 1 had been triggered for the use of restraints from July 07, 2022, to August 11, 2022. On Patient 1's Treatment Administration Records (TAR) dated from June 7, 2022, through August 11, 2022, there was no documented evidence the shackles/restraints had been removed and the skin checked as indicated in care plan. During observation of Patient 1 on August 11, 2022, at 4:14 PM, in the Red Zone (a separation of patients who have tested positive for COVID 19 a contagious respiratory virus), Resident 1 was lying in bed unshackled with one end of the shackle attached to the bedrail. During an observation on August 15, 2022, at 2:15 PM, Patient 1 was observed sitting on side of the bed, no shackle was noted on either ankle. One end of the shackle was attached to the bedrail and both of Patient 1's legs appeared to have mild swelling. 2. Patient 2 was a 70-year-old female admitted to the facility on June 22, 2022, with diagnosis which included aftercare following joint replacement surgery, schizophrenia (thought disorder characterized by hallucinations and delusions), history of in-situ neoplasm of cervix uteri (early stage of cervical cancer). During a concurrent observation and interview of Patient 2 on August 10, 2022, at 2:16PM, her left ankle was shackled to the bedrail. Patient 2 stated, the corrections officer will release the shackle only for showers and when working with Physical Therapy, but an officer will remain at Patient 2's side during that time. During an interview on August 10, 2022, at 2:24 PM, with a Correctional Officer1 (CO 1), the officer stated," We have officers here 24 hours 7 days a week for these patients. The shackles are on because they are in our custody, per our Policy and Procedure. Because they are under our custody, they have them on." The CO 1 further stated, It really depends on the Patient's behavior, we give (JIP) a courtesy." During review of Patient 2's Physician's Orders on August 11, 2022, at 11:14AM, a Physician Order dated June 23, 2022, at 11:18 AM, indicated, "Patient under the custody of California Department of Correction and Rehabilitation (CDCR, [name of State Hospital] Patients) is under jurisdiction of CDCR. "CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape." (Exhibit A section S 2016 DSH- [name of state hospital] contract) Patient is a risk for negative effects of use of shackle such as skin discoloration, impaired circulation, and skin break down." During review of Patient 2's medical records under "Nurses Progress Notes" on August 11, 2022, at 11:20 AM, there was no documented evidence of restraint assessments, or skin assessments due to shackles/restraints being done since Patient 2's admission to the facility on June 22, 2022, through August 11, 2022. Under the section for the MDS (Minimum Data Set- a computerized assessment tool), there was no documented evidence Resident 2 had been triggered for the use of restraints from June 22, 2022, through August 11, 2022. On Patient 2's Treatment Administration Records (TAR) there was no documented evidence the shackles/restraints had been removed and the skin checked as indicated in the care plan. During a concurrent follow-up observation and interview of Patient 2 on August 15, 2022, at 2:15PM, it was noted there was a shackle to the left ankle which was attached to the bedrail. Patient 2 stated, "The nurse does not come and assess my ankle." 3. Patient 3 was a 30-year-old male, admitted to the facility on July 19, 2022, with diagnosis which included unspecified psychosis not due to a substance or known physiological condition, schizophrenia (thought disorder characterized by hallucinations and delusions). During observation of Patient 3 on August 10, 2022, at 2:21 PM, a shackle was noted on his left ankle attached to the bedrail. During an interview on August 10,2022, at 2:36 PM, with a Certified Nursing Assistant (CNA1), CNA 1 stated, "These patients don't go to activities, the most they do is walk the hallways with physical therapy with the C.O. They don't have activities here. These patients are shackled." During review of Patient 3's Physician Orders on August 11, 2022, at 11:14 AM, a Physician Order dated July 19, 2022, at 6:22 PM, indicated, "Patient under the custody of California Department of Correction and Rehabilitation (CDCR, [name of State Hospital] Patients) is under jurisdiction of CDCR. "CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape." (Exhibit A section S 2016 DSH- [name of State Hospital] contract) Patient is at risk for negative effects of use of shackle such as skin discoloration, impaired circulation, and skin break down." During review of Patient 3's medical records under "Nurses Progress Notes" on August 11, 2022, at 11:22 AM, there was no documented evidence of restraint assessments, or skin assessments due to shackles/restraints being done since Patient 3's admission date of July 19, 2022, through August 11, 2022. Under the section for the MDS (Minimum Data Set- a computerized assessment tool), there was no documented evidence Patient 3 had been triggered for the use of restraints from July 19, 2022, through August 11, 2022. Resident 3's Treatment Administration Records (TAR) had no documented evidence the shackles/restraints had been removed and the skin checked as indicated in care plan. During a concurrent observation and interview with Patient 3 on August 11, 2022, at 1:21 PM, when observed he had a shackle to his ankle attached to the bed and asked, "How do you feel about the shackle?" Patient stated "It's normal. " 4. Patient 4 was a 67-year-old male, admitted to the facility on August 06, 2022, with diagnoses which included end stage renal disease (kidney failure), encounter for adequacy for hemodialysis (filter waste and water from blood), benign prostatic hyperplasia with lower urinary tract symptoms (enlarge prostate), schizophrenia (thought disorder characterized by hallucinations and delusions). During observation of Patient 4 on August 10, 2022, at 2:22PM, Patient 4 was observed to have his left ankle shackled to the bedrail. During an interview on August 10, 2022, 2:41PM, with a licensed vocational nurse (LVN2), LVN 2 stated she was not sure how long the justice involved patients (JIP) are shackled for and stated that the COs will unshackle them. LVN 2 indicated only these JIP are shackled in this facility. During interview on August 10, 2022, at 3:01 PM, with the MDS (Minimum data set- a computerized assessment program) Nurse, stated," There is a CO 24/7 (24 hours a day, seven days a week) with these patients. They have shackles on while in bed. The patient can stand on side of bed, [the] chain is long enough." The MDS Nurses further stated, "It depends on the CO if they have it [the shackles] on or off. They don't go to activities, because they cannot be with other patients, the Activities Director will give them activities in room, but the CO must go through it." During interview with the Director of Nursing (DON) on August 10, 2022, at 3:13 PM, the DON stated, "We get these patients from State hospital, court ordered. They could come to us with a CO at bedside and shackles. They are on no gradual dose reduction on psych[iatric] meds(medication) because they might kill. Each of the pati