Other·March 6, 2024

The following reflects the findings of the California Department of Public Health during a recertification survey regarding investigation patient's bed rails. Event ID: VYST11 Exit Date: 01/23/24 Representing the Department: 46552, Health Facilities Evaluator Nurses and 46001, Health Facilities Evaluator Nurses State Citation B was issued. F700 §483.25(n) Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side orbed 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)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. On 1/16/24, an unannounced recertification survey was conducted at the facility. The facility failed to follow their bed rails (bed rails, safety rails, side rails, grab/assist bars: adjustable metal or rigid plastic bars that attached to the bed) policy when there was no documentation that alternatives for bed rails were attempted prior to installing for Patients 3,4,6,7,8,12,13,14,20,24,128,129, 130,131,132, 178,179,180,181,182,183,184,185,186 and 187. There was no informed consent prior to installing bed rails for Patients 183, 181, 8, 187, 186, 182, 180, 3, 132, 128, 129, 24, 20, 7, 131, and 6. These failures resulted in the patients and patient's RPs not being fully informed on the risks of the use of bed rails and had the potential to place the patient at risk of serious injury. During an observation on 1/16/24 at 10:55 a.m., Patient 8's bed had partial bed rails up on both sides. Review of Patient 8's face sheet (a document that gives resident's information at a quick glance) indicated Patient 8 was readmitted to the facility on 11/23/23. The face sheet also indicated Patient 8 was self-responsible. Review of Patient 8's minimum data set (MDS, resident's clinical and functional assessment tool) assessment, dated 11/29/23, indicated Patient 8's had a brief interview for mental status (BIMS, an assessment used in nursing homes to monitor cognition) score of 14 (score of 13-15 indicates an intact cognition). Review of Patient 8's physician's order, dated 11/23/23, indicated Patient 8 had an order for bilateral (both sides) upper grab rails for bed mobility/positioning and/or transfer. Review of Patient 8's bed rail observation/assessment, dated 10/30/23, indicated there was no documentation that the facility attempted alternatives, and obtained informed consent prior to installing bed rails. During an interview with Patient 8 on 1/18/24 at 1:30 p.m., Patient 8 confirmed the facility did not provide alternatives for bed rails. During an observation on 1/16/24 at 11:05 a.m., Patient 178's bed had bilateral, partial bed rails up. Review of Patient 178's face sheet indicated Patient 178 was admitted to facility on 1/12/24. The face sheet also indicated Patient 178 had an assigned RP. Review of Patient 178's MDS assessment, dated 01/18/24, indicated Patient 178 had a BIMS score of 12, (score of 8-12 indicates moderately impaired cognition). Review of Patient's 178's physician's order, dated 1/12/24, indicated Patient 178 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. Patient 178 also had an order, dated 1/12/24, indicated Patient 178 was capable of understanding rights, responsibilities, and informed consent. Review of Patient 178's bed rail observation/assessment, dated 1/12/24, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. During an interview with Patient 178 on 1/16/24 at 11:22 a.m., Patient 178 confirmed the facility did not use alternatives prior to use of bed rails. During an observation on 1/16/24 at 11:22 a.m., Patient 179's bed had partial bed rails up on both sides. Review of Patient 179's face sheet indicated patient 179 was admitted to the facility on 12/16/23. The face sheet also indicated Patient 179 was self-responsible. Review of Patient 179's MDS assessment, dated 12/29/23, indicated Patient 179 had a BIMS score of 9. Review of Patient179's physician's order, dated 1/7/24, indicated Patient 179 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. Review of Patient 179's bed rail observation/assessment, dated 12/16/23, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. During an interview with Patient 179 on 1/16/24 at 11:22 a.m., Patient 179 confirmed the facility did not use alternatives prior to the use of bed rails. During an observation on 1/16/24 at 11:45 a.m., Patient 184's bed had partial bed rails up on both sides. Review of Patient 184's face sheet indicated Patient 184 was admitted to the facility on 1/14/24. The face sheet also indicated Patient 184 was self-responsible. Review of Patient 184's MDS assessment, dated 1/20/24, indicated Patient 184 had a BIMS score of 13. Review of Patient 184's physician's order, dated 1/14/24, indicated Patient 184 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. Review of Patient 184's bed rail observation/assessment, dated 1/14/24, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. During an interview with Patient 184 on 1/16/24 at 11:45 a.m., Patient 184 confirmed the facility did not use alternatives prior to the use of bed rails. During an observation on 1/16/24 at 11:53 a.m., Patient 181's bed had partial bed rails up on both sides. Review of Patient 181's face sheet indicated Patient 181 was admitted to the facility on 01/07/24. The face sheet also indicated Patient 181 was self-responsible. Review of Patient 181's MDS assessment, dated 01/13/24, indicated Patient 181 had a BIMS score of 14. Review of Patient 181's physician's order, dated 1/7/24, indicated there was no order for bed rails. Review of Patient 181's bed rail observation/assessment, dated 01/07/24, indicated there was no documentation that the facility attempted alternatives, and obtained informed consent prior to the installation of bed rails. During an interview with Patient 181 on 1/16/24 at 11:53 a.m., Patient 181 confirmed the facility did not provide alternatives for bed rails. During an observation on 1/16/24 at 12:15 p.m., Patient 12's bed had bilateral partial bed rails up. Review of Patient 12's face sheet indicated Patient 12 was admitted to the facility on 12/11/23. The face sheet also indicated Patient 12 had assigned RP. Review of Patient 12's MDS assessment, dated 12/17/23, indicated Patient 12 had a BIMS score of 9. Review of Patient 12's physician's order, dated 12/11/23, indicated Patient 12 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. Patient 12 also had an order, dated 12/11/23 indicated Patient 12 was capable of understanding rights, responsibilities, and informed consent. Review of Patient 12's bed rail observation/assessment, dated 12/11/23, indicated there was no documentation that the facility attempted alternatives prior to the use of bed rails. During an interview with Patient 12 on 1/16/24 at 12:15 p.m., Patient 12 confirmed the facility did not use alternatives prior to the use of bed rails. During an observation on 1/16/24 at 11:48 a.m., Patient 182's bed had bilateral partial bed rails up. Review of Patient 182's face sheet indicated Patient 182 was admitted to the facility on 1/10/24. The face sheet also indicated Patient 182 had an assigned RP. Review of Patient 182's MDS assessment, dated 1/16/24, indicated Patient 182 had a BIMS score of 14. Review of Patient 182's physician's order, dated 1/10/24, indicated Patient 182 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. Review of Patient 182's bed rail observation/assessment, dated 1/10/24, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. During an interview with Patient 182 on 1/16/24 at 11:48 a.m., Patient 182 confirmed the facility did not use alternatives prior to the use of bed rails. During an observation on 1/16/24 at 12:10 p.m., Patient 187's bed had bilateral partial bed rails up. Review of Patient 187's face sheet indicated Patient 187 was admitted to the facility on 11/5/23. The face sheet also indicated Patient 187 had an assigned RP. Review of Patient 187's MDS assessment, dated 11/30/23, indicated Patient 187 had a BIMS score of 4 (score of 0-7 indicates severe cognitive impairment). Review of Patient 187's physician's order, dated 11/24/23, indicated Patient 187 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. Review of Patient 187's bed rail observation/assessment, dated 11/24/23, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. During a telephone interview on 1/18/24 at 3:30 p.m., with Patient 187's RP, the RP stated Patient 187 had bed rails since the resident was admitted to the facility. During an observation on 1/16/24 at 11:59 a.m., Patient 3's bed had bilateral partial bed rails up. Review of Patient 3's face sheet indicated Patient 3 was admitted to the facility on 12/5/23. The face sheet also indicated Patient 3 was self-responsible. Review of Patient 3's MDS assessment dated 12/11/23, indicated Patient 3 had a BIMS score of 12. Review of Patient's 3's physician's order, dated 12/5/23, indicated Patient 3 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. Review of Patient 3's bed rail observation/assessment, dated 12/5/23, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails and there was no informed consent. During an interview with Patient 3 on 1/16/24 at 11:59 a.m., Patient 3 acknowledged that the facility did not provide alternatives prior to the use of bed rails. During an observation on 1/16/24 at 11:38 a.m., Patient 186's bed had bilateral partial bed rails up. Review of Patient 186's face sheet indicated patient 186 was admitted to the facility on 1/9/24. The face sheet also indicated Patient 186 had an assigned RP. Review of Patient 186's MDS assessment, dated 1/12/24 indicated Patient 186 had a BIMS score of 15. Review of Patient 186's physician's order, dated 1/9/2024, indicated there was no order for the use of bed rails. Review of Patient 186's bed rail observation/assessment, dated 1/9/24, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. During an interview with Patient 186 on 1/1/6/24 at 11:38 a.m., Patient 186 acknowledged there were no alternatives tried prior to the use of bed rails. During an observation on 1/16/24 at 11:42 a.m., Patient 180's bed had bilateral partial bed rails up. Review of Resident 180's face sheet indicated Patient 180 was admitted to the facility on 1/4/24. The face sheet also indicated Patient 180 had an assigned RP. Review of Patient 180's MDS assessment, dated 1/7/24 indicated Patient 180 had a BIMS score of 0 (score of 0 indicates severely impaired cognition). Review of Patient 180's physician's order, dated 1/4/24, indicated there was no order for the use of bed rails. Review of Patient 180's bed rail observation/assessment, dated 1/4/24, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails and there was no informed consent. During an interview with Patient 180's RP on 1/16/24 at 11:42 a.m., Patient 180's RP confirmed there were no alternatives provided prior to the use of bed rails. During an observation on 1/16/24 at 11:30 a.m., Patient 183's bed had bilateral partial bed rails up. Review of Patient 183's face sheet indicated Patient 183 was admitted to the facility on 1/11/24. The face sheet also indicated Patient 183 had an assigned RP. Review of Patient 183's MDS assessment, dated 1/17/24, indicated Patient 183 had a BIMS score of 13. Review of Patient 183's physician's order, dated 1/11/24, indicated Patient 183 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. Review of Patient 183's bed rail observation/assessment, dated 1/11/24, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. During a telephone interview with Patient 183's RP on 1/18/24 at 2:10 p.m., Patient 183's RP stated Patient 183's bed had side rails since the patient was admitted to the facility. During an observation on 1/16/24 at 12:40 p.m., Patient 185's bed had bilateral partial bed rails up. Review of Patient 185's face sheet indicated Patient 185 was admitted to the facility on 1/1/24. The face sheet also indicated Patient 185 was self- responsible. Review of Patient 185's MDS assessment, dated 1/7/24 indicated, Patient 185 had a BIMS score of 12. Review of Patient 185's physician's order, dated 1/1/24, indicated there was no order for the use of bed rails. Review of Patient 185's bed rail observation/assessment, dated 1/1/24, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. During an interview with Patient 185 on 1/16/24 at 12:40 p.m., Patient 185 stated there were no alternatives provided by the facility prior to the use of bed rails. During an observation on 1/16/24 at 11:15 a.m., Patient 14's bed had bilateral partial bed rails up. Review of Patient 14's face sheet indicated Patient 14 was admitted to the facility on 9/7/22. The face sheet also indicated Patient 14 had an assigned RP. Review of Patient 14's MDS assessment, dated 11/15/23, indicated Patient 14 had a BIMS score of 5. Review of Patient 14's physician's order, dated 11/17/23, indicated Patient 14 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. Review of Patient 14's bed rail observation/assessment, dated 9/17/22, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. Review of Patient 182's bed rail observation/assessment, dated 1/10/24 indicated there was no informed consent for the use of side rails. Review of Patient 183's bed rail observation/assessment, dated 1/11/24, indicated there was no informed consent for the use of side rails. Review of Patient 186's bed rail observation/assessment, dated 1/9/24, indicated there was no informed consent for the use of side rails. Review of Patient 187's bed rail observation/assessment, dated 11/24/23, indicated there was no informed consent for the use of side rails. During a concurrent interview and record review with the director of nursing (DON) on 1/18/24 5:47 p.m., the DON reviewed the bed rails assessments of the 25 patients and confirmed the facility did not have alternatives and there was no documentation for unsuccessful attempts to use alternatives prior to the use of bed rails. The DON further stated the facility should have tried alternatives and staff should have followed the facility's policy to document unsuccessful attempts of alternatives prior to use of bed rails. During an interview with the DON on 1/19/24 at 12:15 p.m., the DON confirmed informed consent was not obtained prior to the use of bed rails for patients 8, 181, 183, 187, 186, 182, 180, and 3. The DON also confirmed there was no physician's order for the use of bed rails for patients 180, 181, 185, and 186. The DON stated the staff should obtain a physician's order then obtain informed consent from the patient/RP prior to the use of bed rails. During an observation on 1/16/24 at 10 a.m., the beds of patients 132,4,128,129,24,20, 130,7,13,131 and 6 were inspected. All 11 beds had partial bed rails bilaterally. Review of Patient 132's physician's order, dated 1/6/24, indicated to put bilateral upper grab rails for bed mobility, position