Health inspection·May 12, 2023

F700 42CFR §483.25(n) Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed 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)(1) Assess the resident for risk of entrapment from bed rails prior to installation. §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. §483.25(n)(3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. §483.25(n)(4) Follow the manufacturers’ recommendations and specifications for installing and maintaining bed rails. 22 CCR § 72319 - Nursing Service - Restraints and Postural Supports (a) Written policies and procedures concerning the use of restraints and postural supports shall be followed. On 3/31/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a recertification survey. The facility failed to ensure the resident has the right to be treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) when the side rails (SRs, also referred to as bed rails or bed side rails, are adjustable metal or rigid plastic bars that attach to the bed that may be positioned in various locations on the bed upper or lower, either or both sides) were raised on both sides of the bed for 18 residents Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18. The facility failed to: 1. Attempt to use appropriate alternatives prior to using SRs. 2. Conduct an assessment including the risk for entrapment from SRs. 3. Review the risk and benefits of side or bed rails with the resident or resident representative and obtain informed consent. As a result, the 18 residents were placed at high risk of negative psychosocial outcome, decline in mobility, isolation, physical harm from entrapment (occurs when a resident is caught between the mattress and SR or within the SR itself), and a falling hazard. a. A review of Resident 17's Admission Record (Face Sheet) indicated the facility admitted the resident on 3/31/2022 with diagnoses that included respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen) and acute renal failure (sudden reduction in kidney function). A review of Resident 17's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/29/2022, indicated the resident was usually able to understand and be understood. Resident 17 was totally dependent on staff for transfers and toilet use and required extensive staff assistance with bed mobility, dressing, eating, and personal hygiene. The MDS further indicated the resident did not use SRs up as a physical restraint. A review of the Physician's Order for Resident 17, dated 10/11/2022, indicated an order for two SRs as enablers and for turning and repositioning. A review of Resident 17's Plan of Care (POC) developed for the resident's risk for injury or falls, initiated 1/4/2023, indicated the resident had a history of trying to get out of bed unassisted, moved a lot on bed. An added note to the POC indicated Resident 17 was found on the floor next to the bed on 6/23/2023 with no injuries. The POC interventions included applying SRs when in bed as ordered. During an observation on 3/31/2023 at 7 p.m., Resident 17 was lying in bed awake with the four (two half on each side) SRs in raised position. Resident did not respond when asked why all the SRs were up. On 4/1/2023 at 7:15 a.m., during an observation of Resident 17 in bed with Licensed Vocational Nurse 3 (LVN 3), the resident had all four SRs up. LVN 3 stated they (nursing staff) always kept all four SRs up for all the residents at night and it had been, and this facility practice was in place for a long time. LVN 3 stated most residents were not able to walk and had minimal movement. LVN 3 stated sometimes the residents move to the side of the bed and having the SR up was a safety measure and fall precaution. LVN 3 stated Resident 17 was unpredictable, moved a lot in bed, and could turn side to side. On 4/1/2023 at 7:20 a.m., LVN 3 reviewed the physician's orders for Resident 17 and stated the order indicated to have the upper two SRs up, but the resident had all four SRs up because he could fall. During an interview on 4/1/2023 at 7:35 a.m., Registered Nurse 1 (RN 1) stated there were times when Resident 17 tried to put his legs out of the bed, and they use four SRs to prevent him from falling. RN 1 stated they do not always use four SRs, sometimes two. RN 1 stated Resident 17 did not try to get out of bed. RN 1 stated the use of four SRs up was restraint and the physician's order was not followed. b. A review of Resident 10's Admission Record indicated the facility admitted the resident on 1/17/2020 with the last readmission dated 7/7/2022. Resident 10's diagnoses included chronic respiratory failure, dependence on a ventilator (a machine that takes over the work of breathing when a person is not able to breathe on their own), and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 10's MDS, dated 2/3/2023, indicated the resident rarely/never communicated and was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not use SRs up as physical restraint. A review of the Physician's Order for Resident 10, dated 7/7/2022, indicated to have four SRs padded for seizures disorder. A review of Resident 10's POC developed on 1/4/2023 for the resident's risk for injury or fall related to seizure, dementia, torso cough reflex (an involuntary response of the body to clear the airway and lungs of irritants) from spontaneous coughing due to tracheostomy, episodes of restlessness, dangling legs over the SRs, history of being found sitting next to bed, the interventions included applying SRs up when in bed as ordered. During an observation on 3/31/2023 at 7:30 p.m., Resident 10 was lying in bed awake, but did not respond to questions. The four SRs were up and padded. On 4/1/2023 at 7:15 a.m., during an observation with LVN 3, Resident 10 was in bed with all four SRs up. During an interview and record review on 4/1/2023 at 5 p.m., RN 1 stated the risk of SRs was that residents could get injury from being stuck. After reviewing the physician's orders, care plans, informed consents, interdisciplinary team (IDT) notes, and assessments for Resident 10, stated Resident 10 sometimes slides due to the use of a low air loss mattress (LALM - a mattress composed of inflatable air cushions that is used to relieve pressure on body parts). RN 1 stated there was no documentation of informed consent for SRs, no initial assessment for SR use, and no care plan for restraints. c. A review of Resident 8's Admission Record indicated the facility admitted the resident on 11/20/2022 with a readmission dated 1/9/2023. Resident 8's diagnoses included acute hypoxic respiratory failure (sudden inability of the lungs to maintain normal respiratory function occurs when there is not enough oxygen in the blood) and on mechanical ventilation and tracheostomy (opening surgically created through the front of the neck and into the trachea [windpipe]). A review of Resident 8's MDS, dated 12/1/2021, indicated the resident rarely / never understood others or make himself understood. The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not have SRs up used as a physical restraint. A review of the Physician's Order for Resident 8, dated11/20/2022, indicated two SRs up for torso cough reflex. A review of Resident 8's POC initiated on 1/5/2023 for Resident 8's risk for fall related to torso reflex from spontaneous coughing due to tracheostomy, included in the interventions applying SRs up when in bed as ordered. On 3/31/2023 at 6:20 p.m., Resident 8 was observed lying in bed with four SRs in raised position. On 4/1/2023 at 7:15 a.m., during an observation with LVN 3, Resident 1 was in bed and upon interview LVN 3 stated Resident 8 had all four SRs up. During an interview and record review on 4/1/2023 at 5 p.m., RN 1 stated one of the risks of the use of SRs up was entrapment (residents can get injury from being stuck). RN 1 after reviewing Resident 8's physician's orders, care plans, informed consents, IDT notes, and assessments, stated there was no documented evidence of informed consent for SRs, initial assessment for SR use, or care plan for restraints. d. A review of Resident 18's Admission Record indicated the facility admitted the resident on 8/28/2014 with a readmission dated 12/6/2020. Resident 18's diagnoses included cranial cerebral trauma (skull and brain injury), respiratory failure, ventilator dependence, and tracheostomy. A review of the Physician's Order for Resident 18, dated 11/20/2022, indicated four SRs up for seizure precaution. A review of Resident 18's POC initiated 1/5/2023, for the resident's risk for injury or fall related to torso reflex from spontaneous coughing due to tracheostomy and taking anti-seizure medication, included in the interventions applying SRs up when in bed as ordered. A review of Resident 18's MDS, dated 3/8/2023, indicated the resident was in a persistent vegetative state (unaware of self or the environment). The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not have SRs up used as physical restraint. During an observation on 3/31/2023 at 6:15 p.m., Resident 18 was lying in bed and did not open eyes or verbally respond to questions. Resident 18 had four SRs in raised position. During an observation and interview on 4/1/2023 at 7:15 a.m., LVN 3 stated Resident 18 had all four SRs up. On 4/1/2023 at 5 p.m., during an interview, record review RN 1 stated the risk of SRs is (residents) can get injury from being stuck. RN 1 reviewed Resident 18's physician's orders, care plans, informed consents, IDT notes, and assessments. RN 1 stated Resident 18 had a diagnosis of brain trauma and brain related issues. RN 1 stated there was a physician's order for four SRs for seizures. RN 1 stated there was no documented evidence of informed consent for SRs, initial assessment for SR use, or care plan for restraints. e. A review of Resident 6's Admission Record indicated the facility admitted the resident on 4/1/2013 with a readmission dated 9/15/2019. Resident 6's diagnoses including respiratory failure, tracheostomy, and left sided brain injury due to ruptured aneurysm (a break or burst of a blood vessel in the brain that causes bleeding) with right sided hemiplegia (mild to severe loss of strength or paralysis on one side of the body). A review of the Physician's Order for Resident 6, dated 11/20/2022, indicated to have four SRs up for seizures disorder. A review of Resident 6's MDS, dated 3/27/2023, indicated the resident rarely/never understood others or made herself understood. Resident 6 was totally dependent on staff for care and did not have SRs up used as physical restraint. A review of Resident 6's POC initiated on 1/4/2023, for the resident's risk for injury due to seizure disorder, included applying SRs up as ordered. During an observation on 3/31/2023 at 6:25 p.m., Resident 6 was lying in bed with four SRs in raised position. During an interview and record review on 4/1/2023 at 5 p.m., RN reviewed Resident 6's physician's orders, care plans, informed consents, IDT notes, and assessments. RN 1 stated there was no documented evidence of informed consent for SRs, initial assessment for SRs up use, or care plan for restraints. f. A review of Resident 3's Admission Record indicated the facility admitted the resident on 5/1/2015 with a readmission dated 8/24/2018. Resident 3's diagnoses included Rett syndrome (a rare genetic neurological disorder that leads to severe impairments, affecting nearly every aspect of life), chronic respiratory failure, and ventilator dependence. A review of the Physician's Order for Resident 3, dated 8/24/2018, indicated to have four SRs up for seizures disorder. A review of Resident 3's MDS, dated 5/6/2022, indicated the resident rarely/never made herself understood or understood others. The resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not have SRs up used as physical restraint. A review of Resident 3's POC initiated on 1/4/2023 for the resident's risk for injury due to seizure disorder, included in the interventions applying SRs up when in bed as ordered. During an observation on 3/31/2023 at 6:30 p.m., Resident 3 was lying in bed with two SRs in raised position. During an observation on 4/1/2023 at 7:05 a.m., Resident 3 was lying in bed with four SRs in raised position. During an observation and interview on 4/1/2023 at 7:15 a.m., LVN 3 states Resident 3 had all four SRs up. During an interview and record review on 4/2/2023 at 7:45 a.m., RN 3 reviewed Resident 3's physician's orders, care plans, informed consents, IDT notes, and assessments. RN 3 stated there was no documented evidence of informed consent for SRs, initial assessment for SRs use, or care plan for restraints. RN 3 stated she had never gotten consent for SRs for any residents. g. A review of Resident 1's Admission Record indicated the facility admitted the resident on 2/24/2015 with a readmission dated 2/6/2023. Resident 1's diagnoses included multiple sclerosis (MS, a disease that impacts the brain, spinal cord, and optic nerves), respiratory failure, and ventilator dependence. A review of Resident 1's MDS, dated 3/4/2022, indicated the resident usually made himself understood and usually understood others. The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not use SRs up as physical restraint. A review of the Physician's Order, dated 2/6/2023, indicated two SRs up for torso cough reflex. A review of Resident 1's POC initiated 2/7/2023 for the resident's risk for injury or fall related to advanced MS and torso reflex from spontaneous coughing due to tracheostomy, included in the interventions applying SRs when in bed as ordered. During an observation on 3/31/2023 at 6:40 p.m., Resident 1 lying in bed with two SRs in raised position. During an observatio