Other·December 27, 2023

§ 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. (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 means 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. (g) Restraints shall be used in such a way as not to cause physical injury to the patient and to insure the least possible discomfort to the patient. (h) Physical restraints shall be applied in such a manner that they can be speedily removed in case of fire or other emergency. (i) The requirements for the use of physical restraints are: (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. (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. (A) Physical restraints for behavioral control shall only be used with a written order designed to lead to a less restrictive way of managing, and ultimately to the elimination of the behavior for which the restraint is applied. There shall be no PRN orders for behavioral restraints. (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. F604 §483.10(e) Respect and Dignity. The patient has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). On 11/17/2023 at 9:45 AM, an unannounced visit was made to the facility for a complaint regarding an alleged violation of patient’s (resident) rights and restraints. As a result of the investigation, the Department determined that the facility failed to ensure Patient 1 was free from physical restraints in accordance with the facility policy and procedure on “Physical Restraint Application.” On 11/15/2023 from 9:30 AM to 10:45 AM (one hour and 15 minutes) while waiting for Patient 1 to be evaluated by the Psychiatric Evaluation Team (PET), emergency medical technicians (EMT) applied physical restraints that was attached to a gurney to Patient 1’s wrists and ankle without a physician’s order, on-going assessments and monitoring of the patient while lying on the gurney in front of the Nursing Station. This failure resulted in Patient 1’s restriction of freedom of movement and had the potential to result in the resident’s increased anxiety, agitation, and loss of dignity. A review of Patient 1’s Face Sheet (document that gives a patient’s information such as contact details and brief medical history) indicated the facility admitted Patient 1, a 66 year old female patient, on 9/12/2023, with diagnoses that included major depressive disorder, severe with psych symptoms (a distinct type of depressive illness in which mood disturbance is accompanied by either delusions, hallucinations or both), generalized anxiety disorder (condition of excessive worry about everyday issues and situations) and schizoaffective disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucination or delusions, and mood disorder symptoms, such as depression or mania.) A review of Patient 1’s Patient Care Plan: Behavior, dated 9/12/2023, indicated Patient 1 needed behavior management for the diagnosis of anxiety as manifested by restlessness. The care plan approach included giving Clonazepam (medication used to treat agitation) 0.5 mg as ordered to manage Patient 1’s behavior. A review of Patient 1’s Order Summary Report for November 2023, indicated a physician order dated 11/11/2023, to administer Clonazepam 0.5 mg every 8 hours PRN (as needed) for agitation, for 14 days. A review of Patient 1’s Minimum Data Set (MDS – a standardized assessment and care planning tool) dated 9/18/2023, indicated Patient 1 had moderately impaired cognition (ability to think, remember, and reason). The MDS indicated Patient 1 had behavioral symptoms not directed towards others (e.g., hitting or scratching self, screaming, disruptive sounds) and had a history of rejecting evaluation or care (e.g., bloodwork, taking medications, ADL assistance). During a review of Patient 1’s Physician Telephone Orders, dated 11/15/2023 (no time), the Physician Telephone Orders indicated Patient 1 was to be transferred to GACH via 5150 (California Welfare and Institutions Code that allows for a 72 hours involuntary hold for treatment; criteria for hold includes a person exhibiting mental health issues that pose a threat to themselves or others, or are gravely disabled) for psychiatric evaluation, with bed hold for 7 days. During a review of Patient 1’s Progress Notes, dated 11/15/2023 at 10:45AM and signed by the Registered Nurse Supervisor (RNS), the Progress Notes indicated Patient 1 “left in the facility via ambulance (5150) in her usual self.” During an interview on 11/17/2023 at 10:49 AM with the RNS, the RNS stated Patient 1’s discharge plan to transfer to an acute hospital was initiated on 11/14/2023, but Patient 1 was not transferred until 11/15/2023 (one day later), because the facility was waiting for the PET’s evaluation and for transportation. The RNS stated the PET needed to determine if Patient 1 was a danger to self or others. The RNS stated that the EMTs (Emergency Medical Technicians – emergency response ambulance staff) arrived at the facility on 11/15/2023 at 9:30 AM to pick up Patient 1, however, Patient 1 was not evaluated by the PET until around 10:08 AM, on 11/15/2023. The RNS stated that she did not transfer Patient 1 to the EMTs until she received the 5150 paperwork from the PET evaluation at around 10:30 AM. The RNS stated that Patient 1 was not transferred to the GACH until about 10:45 AM, on 11/15/2023, via ambulance. During a concurrent interview and record review, on 11/17/2023, at 11:02 AM, with the RNS, Patient 1’s physician progress notes from Psychiatrist 1, [undated] was reviewed. The RNS stated Psychiatrist 1 ordered Patient 1 to be discharged on 11/14/2023, but the RNS wrote the order to transfer the patient on 11/15/2023. The RNS stated Psychiatrist 1 came to the facility on 11/15/2023, but Patient 1 had already been transferred. The RNS stated she did not find notes from Psychiatrist 1 about Patient 1’s behavior and PET evaluation for 5150 transfer. On 11/17/2023 at 12:05 PM, during a concurrent review and interview of the security camera surveillance footage of the facility lobby with the Administrator (ADM) and Maintenance Supervisor (MS), inside the ADM’s office, the surveillance footage timestamped dated 11/15/2023, at 9:34 AM, showed two EMTs entering the facility’s front lobby entrance with an empty gurney. The MS stated that the facility’s security camera surveillance footage had about a 12-minute delay between the actual time and the time shown on the surveillance footage. During the continued review of the facility’s security camera surveillance footage, timestamped at 10:54 AM, the surveillance footage showed Patient 1 leaving the facility with the two EMTs via gurney. The facility’s security camera surveillance footage showed Patient 1 lying on the gurney with bilateral wrists and bilateral ankles soft restraints secured to the gurney. The ADM stated Patient 1 exhibited delusions that day, including believing there were cameras in her room and her roommate was somebody else (another name referred to a God). The ADM stated he believed Patient 1’s transfer took time because the EMTs were waiting for Patient 1 to agree with the transfer as ordered by the physician. The ADM stated the details of what transpired should be documented in Patient 1’s records. During an interview on 11/17/2023 at 12:47 PM with the ADM, the ADM stated the facility does not use physical restraints with its patients. The ADM stated Psychiatrist 1 comes to the facility to evaluate patients once every two weeks, and leaves progress notes in the patients’ charts. During an interview on 11/17/2023 at 1:24 PM with the facility’s Receptionist (RCP), the RCP stated that in the morning of 11/15/2023, the RCP saw Patient 1 angrily banging on tables. The RCP stated when the EMTs arrived at the facility on 11/15/2023, Patient 1 was walking the hallways of the facility. The RCP stated she was not monitoring Patient 1 but believed Patient 1 was placed in the gurney when the EMTs arrived. The RCP stated Patient 1 was discharged out of the facility at around 10:45AM. During an interview on 11/17/2023 at 1:53 PM with the RNS, the RNS stated the order for Patient 1’s transfer on 5150 was endorsed to her by the previous shift. The RNS stated there was a discussion on 11/14/2023, but she was not working that day; during that discussion, Psychiatrist 1 instructed the facility to call the PET for a 5150 hold for Patient 1. The RNS stated PET evaluation for Patient 1 was conducted via a phone call on 11/15/2023 at around 10:08AM. The RNS stated the facility received the 5150 transfer order form via fax at around 10:30 AM. The RNS stated the EMT’s ambulance arrived at around 9:30 AM, and during that time, Patient 1 was walking around the facility. The RNS further stated the EMTs immediately placed Patient 1 on restraints because Patient 1 was fighting. During an interview on 11/17/1023 at 2:09 PM with the Director of Nursing (DON), the DON stated that on 11/14/2023, Psychiatrist 1 instructed the facility to transfer Patient 1 to the GACH. The DON stated the licensed nurses should prepare the paperwork needed for the transfer and continue to observe the resident. The DON stated the facility practice was the facility’s case manager arranges for the PET to come evaluate the patient and arrange for the transportation. The DON stated the case manager called for an ambulance on 11/14/2023, but they did not come to the facility on 11/14/2023, so the facility followed up again on 11/15/2023. The DON stated the ambulance arrived at the facility around on 11/15/2023 at around 9:30AM and left at 10:45AM. The DON stated when the ambulance came, Patient 1 was paranoid and did not believe the ambulance was for her. The DON stated the facility did not have the 5150 evaluation and order form, so the EMTs could not take Patient 1. The DON stated the facility’s case manager called the PET team to request for the required paperwork again. The DON stated that before the facility case manager called for the transportation or ambulance, the 5150 hold paperwork should had been ready. During the same interview on 11/17/2023 at 2:18 PM with the DON, the DON stated when the two EMTs approached Patient 1, Patient 1 began cursing and yelling saying that was not her ambulance. The DON stated the facility staff assisted the EMTs in putting Patient 1 on the gurney because Patient 1 was kicking and screaming at the EMTs. The DON stated Patient 1 was strapped to the gurney for around one hour while the licensed nurses were obtaining the 5150-hold paperwork from the PET, because the EMTs could not leave without it. The DON stated the facility is restraint-free and it was not the facility’s policy to put the patients in the gurney. The DON stated it was considered a physical restraint if the resident’s wrists/ankles were strapped to the gurney. The DON stated that on 11/15/2023 Patient 1 was strapped in the EMT’s gurney in front of the nurses’ station for about an hour. The DON stated that while Patient 1 was strapped in the gurney, Patient 1 was resisting and kicking the two EMTs. The DON stated that Patient 1’s attending physician was not notified while Patient 1 was combative and yelling during that time and there was no order to apply physical restraints while waiting to be transferred out of the facility. The DON stated Patient 1 was angry, trying to move her hands, and yelling “You will be punished for this... [God] does not like what you’re doing to me.” The DON stated this was not a reason for Patient 1 to be physically restrained to the gurney. The DON stated Patient 1 was placed in front of the Nursing Station while lying on the gurney, for everyone in the facility to supervise. The DON stated there was no documented evidence that facility staff assessed and monitored Patient 1 for complications from physical restraints. During a concurrent interview on 11/17/2023 at 2:56 PM with the Case Manager (CM), in the presence of the DON, the CM stated that she called for an ambulance to transport Patient 1 to the GACH. The CM stated the ambulance was from a private company. The CM stated she could not recall the time of her call to the ambulance company, but the ambulance company informed her that the ambulance was scheduled to arrive within two to three hours from the time of the call. During a concurrent interview and record review on 11/17/2023 at 3:46 PM, with the DON, Patient 1’s Medication Administration Record (MAR) for November 2023 was reviewed. The DON stated that Patient 1 had an order for Clonazepam (medication used to treat agitation) as needed for agitation. The DON stated the MAR did not indicate that Clonazepam was administered to Patient 1 on 11/15/2023 for agitation. The DON stated the Clonazepam was not administered because Patient 1 was refusing medications. The DON stated the MAR did not indicate documented evidence that Patient 1’s physician was notified and refusing medication on 11/15/23 prior to the GACH transfer. A review of the facility’s policy and procedure titled, Physical Restraint Application, dated October 2010, indicated “Physical Restraints are defined as any manual method, or physical, mechanical device, material or equipment attached or adjacent to the resident’s body that the individual cannot remove easily which restricts freedom of movement. The policy and procedure further indicated to verify physician’s order for the use of restraints and review the resident’s care plan to assess for any special needs of the resident, including checking the patient every 30 minutes.” The policy and procedure indicated the following should be recorded in the resident’s medical record: 1. Date and time restraints was applied 2. The name and title of the individual(s) who applied the restraint 3. The type of physical restraint applied 4. The specific reason the restraint was applied 5. The length of time the restraint will be used 6. Each time the device is released for patient exercise, toileting, and position change 7. Each time the patient is monitored. 8. All assessment data (e.g bruises, rashes, sores, etc.) observed duri