Health inspection·February 1, 2024

§483.10(e) Respect and Dignity. The resident 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). §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. (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. (f) Seclusion, which is defined as the placement of a patient alone in a room, shall not be employed. (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. (C) Patients shall be restrained only in an area that is under supervision of staff and shall be afforded protection from other patients who may be in the area. (j) When drugs are used to restrain or control behavior or to treat a disordered thought process, the following shall apply: (1) The specific behavior or manifestation of disordered thought process to be treated with the drug is identified in the patient's health record. (2) The plan of care for each patient specifies data to be collected for use in evaluating the effectiveness of the drugs and the occurrence of adverse reactions. (3) The data collected shall be made available to the prescriber in a consolidated manner at least monthly. (4) PRN orders for such drugs shall be subject to the requirements of this section. (k) "Postural support" means a method other than orthopedic braces used to assist patients to achieve proper body position and balance. Postural supports may only include soft ties, seat belts, spring release trays or cloth vests and shall only be used to improve a patient's mobility and independent functioning, to prevent the patient from falling out of a bed or chair, or for positioning, rather than to restrict movement. These methods shall not be considered restraints. (1) The use of postural support and the method of application shall be specified in the patient's care plan and approved in writing by the physician, psychologist, or other person lawfully authorized to provide care. (2) Postural supports shall be applied: (A) Under the supervision of a licensed nurse. (B) In accordance with principles of good body alignment and with concern for circulation and allowance for change of position. § 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 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. (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. § 72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (24) To be free from psychotherapeutic drugs and physical restraints used for the purpose of patient discipline or staff convenience and to be free from psychotherapeutic drugs used as a chemical restraint as defined in Section 72018, except in an emergency which threatens to bring immediate injury to the patient or others. If a chemical restraint is administered during an emergency, such medication shall be only that which is required to treat the emergency condition and shall be provided in ways that are least restrictive of the personal liberty of the patient and used only for a specified and limited period of time. § 72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 12/11/23 the California Department of Public Health (CDPH) conducted an unannounced recertification survey at the facility. The facility failed to ensure Residents 39, 45, 20, 11, 68 and 27 were free of unnecessary physical restraints (devices that limit a patient's movement), The facility failed to: 1. Ensure staff follow the Physical Restraint Elimination Assessment (assessment used by the facility for restrained residents to determine whether they are candidates for restraint reduction, score of 0-20 is a priority candidate, 21-35 good candidate, and 35 and above is a poor candidate) for Residents 39, 45, 20, 11, 68 and 27 on monthly basis to assess for the continuous need of physical restraints. 2. Ensure staff released Residents 39, 45, 20, 11, 68 and 27 physical restraints every two (2) hours for 15 minutes for blood circulation (the flow of fluid, especially blood) and skin integrity (the skin being whole, intact, and undamaged) assessment. 3. Ensure to use a least restrictive measures (restraint that allows the most freedom of movement while still protecting the resident) prior to use of physical restraints per facility's P&P titled, "Physical Restraints" for Residents 39, 45, 20, 11, 68 and 27. 4. Ensure Resident 39's and Resident 20's soft (soft material or fabric fit around the limbs [arm or leg] of an individual to limit movement and to prevent the dislodgment of tubes, lines, and catheters) wrist restraints were applied with one finger between the cuff and the inside of the resident's wrist to ensure proper fit and secured in the bed frame that moves with the resident per manufacturer (instructions provided by maker of a product to provide detailed insight into how to equipment should be used) guidelines. These failures placed Residents' 39, 45, 20, 11, 68 and 27, at risk for impaired blood circulation, formation of stasis ulcers (medical condition characterized by impaired blood flow in the veins), skin injuries including pressure ulcer (an injury that breaks down the skin and underlying tissue) and psychosocial harm from not being treated with respect and dignity. 1. During an observation on 12/11/2023 at 11:55 a.m. at Resident 39's bedside, Resident 39 was observed non-verbal with a soft wrist restraint on the right wrist, a soft mitten restraint on the right hand and all four siderails up on the bed. A review of Resident 39's Admission Record (Face Sheet) indicated Resident 39, a 55 years old female, was admitted to the facility on 3/9/2022 with diagnoses including respiratory failure (a condition in which your blood doesn't have enough oxygen), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck) and cerebral vascular accident ([CVA] an interruption in the flow of blood to cells in the brain]) with left arm weakness. A review of Resident 39's Minimum Assessment Set ([MDS] - a standardized assessment and care screening tool) dated 11/10/2023, indicated Resident 39 had severe impairment of cognitive (ability to learn, remember, understand, and make decisions) skills for daily decision making and memory impairment. Resident 39 had weakness on both arms and was dependent on staff for all activities of daily living ([ADL]- consist of eating, dressing/grooming, bathing/personal hygiene, mobility (ambulation and transfer), elimination {toileting}). The MDS indicated Resident 39 had a physical restraint on the right upper extremity. A review of Resident 39's Physician's Order dated 3/9/2022, indicated to release Resident 39's right hand soft mitten every two hours for blood circulation check, redness, and safety, and to apply a right soft wrist restraint, release every two hours for blood circulation check, redness, and safety. A review of Resident 39's Restraint Every Two-Hour Monitoring record (documentation log used when residents are in restraints) dated 12/9/2023 and timed at 6 a.m. through 12/14/2023 and timed at 6:15 p.m., the licensed nurses documented Resident 39's behavior was calm in response to the restraints. A review of Resident 39's Restraint Every Two-hour Monitoring record dated 12/9/2023 and timed at 6 a.m. through 12/13/2023 and timed at 4 a.m., indicated no documentation of Resident 39's right soft mitten and right soft wrist restraints were released every two hours for 15 minutes for blood circulation check and skin check. A review of Resident 39's Restraint Every Two-hour Monitoring record dated 12/11/2023 and timed at 6 p.m. through 12/12/2023 and timed at 8 a.m., indicated no documentation Resident 39 was monitored every two (2) hours while on a right soft wrist restraint, and right-hand mitten restraint for blood circulation, and skin integrity. A review of Resident 39's Care Plan titled, "Restraint Care" dated 3/8/2018, indicated the interventions included to assess Resident 39 for least restrictive measures/devices prior to restraint use and to check for proper placement of restraints. The Care Plan indicated the goal was to discontinue the use of restraints on 6/8/2018. A review of Resident 39's Nursing Progress Notes dated 10/1/2023 and timed at 10:22 a.m., indicated no documentation of least restrictive measures were used and were unsuccessful prior to the continuation of the use of restraints (right hand soft mittens and right soft wrist restraint). A review of Resident 39's Nursing Progress Notes dated 10/15/2023 and timed at 10:22 a.m., indicated no documentation of least restrictive measures were used and were unsuccessful prior to the continuation of the use of restraints (right hand soft mittens and right soft wrist restraint). A review of Resident 39's Nursing Progress Noted dated 11/5/2023 and timed at 6:08 p.m., indicated no documentation of least restrictive measures were used and were unsuccessful prior to the continuation of the use of restraints (right hand soft mitten and right soft wrist restraint). A review of Resident 39's Interdisciplinary Team ([IDT] a group of healthcare professional who assess, coordinate, and mange each resident's comprehensive health care, including his or her medical, psychological, social, and functional needs) Meeting dated 9/21/2023, 10/19/2023 and 11/14/2023, indicated no documentation of the least restrictive measures were used and were unsuccessful for Resident 39 prior to the placement of restraints (right soft mitten and right soft wrist restraints). During a concurrent observation and interview on 12/12/2023 at 12:18 p.m. with LVN 12, Resident 39's restraint was observed tied in a knot to the bed frame. LVN 12 stated, the right wrist restraint was tied in the wrong place on a movable part of the bed frame placing the resident at risk for injury. LVN 12 stated it was the responsibility of the licensed nurses to assess and check placement of restraints (right soft mittens and right soft wrist restraint) every two hours. During a concurrent interview and record review on 12/12/2023 on 2:15 p.m. the Nurse Manager (NM 1) stated Resident 39 Physical Restraint Elimination Assessment score was 26. NM 1 stated a score of 21-35 means Resident 39 was a good candidate to have a trial to see if the restraints can be released. During a concurrent interview and record review on 12/14/2023 at 11:51 a.m., the DSD viewed the photograph, taken by the surveyor on 12/12/2023 at 12:26 pm, of Resident 39's right soft wrist restraint placement and stated it was tied in the wrong place on the bed. The DSD stated the way Resident 39 restraint was tied would not enable Resident 39 to use the call light to call for help. During an interview on 12/15/2023 at 9:41 a.m., NM 2 stated the least restrictive meas