Health inspection·October 31, 2023

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to review the risks and benefits of bed rails with the resident or resident's representative and obtain informed consent prior to installation of bed rails for 1 (Resident #1) of 8 residents reviewed for bedrails. The facility failed to inform Resident #1 or her representative of the use of bed rails and obtain consent for the use of bed rails. This deficient practice could place all residents with bed rails at risk for injuries such as abrasion, fractures, and entrapment. Finding include: Record review of Resident #1's clinical record revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), anxiety (a mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), pain, hypertension (a condition in which the foresee of the blood against the artery walls is too high), coronary artery disease (damage or disease in the hearts major blood vessels), arrythmia (a condition in which the heart beats with an irregular or abnormal rhythm), osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), cardiovascular accident (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, and history of falling. Record review of Resident #1's clinical record revealed her last MDS was an admission completed 9-25-2023 which indicated her BIMS was 00 indicating she was severely cognitively impaired, and she had a functionality of requiring one-person assistance with most activities of daily living. Record review of the facility provided Side Rail Release Form for Resident #1 completed by PT/OT revealed the following: Date: 9-18-2023 Patient is released to have one/both side rails on bed by PT/OT Description: Patient released to use handrails for bed mobility, transfer, and repositioning. Record review of the facility provided Side Rail Release Form for Resident #1 completed by PT/OT Page 1 of 3 675498 675498 10/31/2023 Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119

F 0700 revealed the following: Level of Harm - Minimal harm or potential for actual harm Date: 10-9-2023 Patient is released to have one/both side rails on bed by PT/OT Residents Affected - Few Description: Patient re-evaluated for bedrails and bedrails removed due to patient no longer safe for bed mobility, transfers, and repositioning. Record review of the facility investigation report revealed the following: Assessment Date: 10-09-2023 Description of Injury: Resident #1 received a bruise to her arm by getting her arm wrapped around her transfer bar on her bed when she was sleeping. Record review of Resident #1's care plans with date of admit 9-18-2023 with the last conference date of 10-11-2023 revealed no care plans for side rails or bed rails. Record review of Resident #1's clinical record revealed no evidence of a consent for the use of bed rails/side rails was provided to Resident #1 or her representative. During an interview on 10-31-2023 at 11:55 AM the DON stated that Resident #1 did have side rails but that the facility was unable to determine if her bruise was from the side rail or from previous falls. The DON stated that the facility had ¼ side rails, that they were used for transfer assistance, that Resident #1 was reevaluated by physical therapy to see if Resident #1 still needed the side rails, and that Resident #1's side rails were removed after the incident. The DON stated that Resident #1 did not have the side rails currently. The DON then reviewed Resident #1's chart and stated, Unfortunately Resident #1 does not have a consent for the use of her side rail. When asked if ongoing monitoring had been provided for Resident #1 and the use of side rails the DON stated that Resident #1 was a new admission and had not had time for ongoing monitoring. During an interview on 10-31-2023 at 12:19 PM FM A (the representative for Resident #1) stated, I could not tell you if I have seen a consent. It may have been part of the admission packet and I signed so many things. There is nothing about a consent for side rails that I know of. I can tell you they have been removed since the incident. (This surveyor noted during observation that Resident #1 did not have bed rails/side rails on her bed at the time of this investigation) During an interview on 10-31-2023 at 1:29 PM the DON reported that if the side rail consents were not completed that the facility's policy and procedures would not be followed and that was what keeps the residents safe, and that it could and would affect residents' care. The DON stated that bed rail/side rail consents were a part of their admission process and that apparently this one was just missed. Record review of facility provided policy titled Bed Rails and Side Rails, Installation and Use, revision 5-5-2023, revealed the following: Procedures: 4. The risk and befits of bed rails/side rails will be reviewed with the resident and/or responsible party. Consent and physician order will be obtained prior to the installation of bed rails/side 675498 Page 2 of 3 675498 10/31/2023 Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119

F 0700 rails. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675498 Page 3 of 3