Health inspection·May 29, 2024

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, clinical record review, facility documentation, and staff interview, it was determined that the facility failed to ensure one of three residents reviewed was free from physical restraints (Resident 1). Residents Affected - Few Findings include: Review of facility policy, Restraint Policy, undated, revealed: restraint use in our facility will only be considered to treat a medical symptom/condition that endangers the physical safety of the resident or other residents and under the following conditions: 1) as a last resort measure after a trial period where less restrictive measures have been undertaken and proven unsuccessful; 2) with a physician order; 3) with the consent of the resident or legal representative; 4) when the benefits of the restraint outweigh the identified risks. Review of facility orientation packet given to outside nursing staff and nursing students revealed: This is a restraint free facility. Review of nurse aide Employee E5's orientation packet revealed the employee signed acknowledgement of receipt and understanding of the orientation materials on October 7, 2023. Review of Resident 1's clinical record revealed the resident was admitted to the facility April 23, 2024, with diagnoses including Parkinson's (chronic and progressive movement disorder that causes tremors, stiffness or slowing of movement), severe dementia (general decline in cognitive abilities that impacts a person's ability to perform everyday activities. This typically involves problems with memory, thinking, behavior, and motor control) with psychotic disturbance, psychotic disorder with delusions, hallucinations, disorientation, unsteadiness on feet, unspecified abnormalities of gait and mobility, and cognitive communication deficit. Review of Resident 1's admission MDS (minimum data set - periodic assessment of resident care needs) dated April 28, 2024, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 01, indicating severe cognitive impairment. Review of Resident 1's clinical record failed to reveal orders for any type of restraint. Interview with the recreation manager, Employee E3, on May 29, 2024, at approximately 9:50 a.m. revealed that the employee was made aware by the activity aide, Employee E4, on May 13, 2024, at 4:15 p.m., that Resident 1 had a gait belt (a device put on someone who has mobility issues to aid caregivers in moving them) wrapped around their waist and the wheelchair in the dining room. Employee E3 Page 1 of 2 395406 395406 05/29/2024 Luther Acres Manor 400 Saint Luke Dr Lititz, PA 17543

F 0604 Level of Harm - Minimal harm or potential for actual harm stated she then went to the dining room and saw the gait belt tied around Resident 1 and secured in the back of the wheelchair. Resident 1 was asleep at this time. Employee E3 informed nurse aide Employee E5 that the gait belt needed to be removed. Employee E3 stated that Employee E5 expressed understanding and stated they put the gait belt on Resident 1 because the resident had fallen a couple times that day. Employee E5 then removed the gait belt from around Resident 1 at approximately 4:30 p.m. Residents Affected - Few Review of facility investigation revealed witness statements from staff Employees E5, E6, and E7, all stating that Resident 1 had a witnessed fall on May 13, 2024, at 4:00 p.m. when the resident tried to stand from the wheelchair. Interview with the Director of Nursing on May 29, 2024, at approximately 11:00 a.m. revealed because of the witnessed fall at 4:00 p.m., Resident 1 was estimated to have been restrained by the gait belt for approximately a half hour. Interview with the Nursing Home Administrator and Director of Nursing on May 29, 2024, at approximately 12:00 p.m. confirmed the facility does not use restraints and Employee E5 should not have wrapped the gait belt around Resident 1 and the wheelchair as a restraint. 28 Pa. Code: 211.8(d)(e)(f) Restraints 28 Pa. Code:211.10(d) Resident care policies 28 Pa. Code:211.12(d)(1)(5)Nursing services 395406 Page 2 of 2