Health inspection·May 20, 2022

F604 §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. § 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 4/4/2022, an unannounced visit was conducted at the facility for an annual recertification survey. The facility failed to ensure Residents 84, 36, 345, and 80 were free from physical restraints, by not ensuring: 1. Assessments were completed prior to applying the physical restraints. 2. Adequate monitoring and periodic release of the physical restraints to ensure adequate blood circulation and skin integrity. 3. Development and implementation of care plans addressing the use of physical restraints. 4. Least restrictive measures were used prior to the implementation of restraints, per the facility's policy. These deficient practices resulted in the use of unnecessary physical restraints, placing the residents at risk for psychosocial harm from not being treated with respect and dignity; and from physical harm by impeding the circulation of the resident's arms and legs, decline in activities of daily living (ADLs), impaired skin integrity, entrapment or death caused by physical restraints. a. During a review of Resident 84's Admission Record, the admission record indicated Resident 84 was admitted to the facility on 4/3/22. Resident 84's diagnoses included Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors), dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), and marasmic kwashiorkor (a severe protein deficiency, causing fluid retention and a protruding abdomen). During a review of Resident 84's Quarterly Minimum Data Set (MDS), a standardized assessment and screening tool, dated 3/16/22, the MDS indicated the resident had severe cognitive (ability to think and reason) impairment. The MDS indicated Resident 84 required total dependence on staff with bed mobility, transfer, dressing, toilet use, personal hygiene and bathing. During an observation on 4/4/2022 at 10:17 a.m., in the resident's room, Resident 84 was observed in bed awake, and verbal with slurred speech. Resident 84 was lying in a semi-fowlers position (positioned on the back with the head and trunk raised between a 15- and 45-degrees angle) with bilateral (having or relating to two sides) foam bolster wedges underneath his trunk area. Resident 84 was receiving oxygen therapy at two (2) liters per minute (l/m) via nasal cannula (flexible tubing with one end designed to deliver oxygen through the nostrils) and gastrostomy tube ([G-tube] surgically placed device used to give direct access to the stomach to deliver feedings, hydration, or medication) feeding. An abdominal binder (fitted elastic material that goes around your abdomen ) was wrapped around Resident 84 abdomen and bilateral hand mittens. During an interview with Certified Nurse Assistant (CNA) 5 on 4/4/2022 at 10:20 a.m., CNA 5 stated Resident 84's bilateral mittens were always applied to prevent Resident 84 from pulling out his G-tube. CNA 5 confirmed that there was no documentation indicating the on-going assessment and monitoring of Resident 84's bilateral mittens every 2 hours. CNA 5 stated it was very important to release the mittens every 2 hours to prevent skin breakdown. During a concurrent observation and interview with Licensed Vocational Nurse 6 (LVN 6) on 4/5/2022 at 10:48 a.m., Resident 84 was observed with a Stage I pressure ulcer (superficial reddening of the skin that when pressed does not turn white) on the left wrist measuring approximately one (1) centimeter ([cm] unit of measurement) by 3 cm. LVN 6 stated the mittens should have been released every 2 hours to prevent skin breakdown caused by the prolonged period of time the mittens were placed. During a review of Resident 84's Pressure Ulcer Risk assessment dated 4/3/2022, the assessment indicated Resident 84 was at high risk for skin breakdown and prevention protocol should be initiated immediately. During a review of Resident 84's Fall Risk Assessment dated 4/3/2022, the assessment indicated Resident 84 was at high risk for falls and a prevention protocol should be initiated immediately and documented on the care plan. During a review of Resident 84's Bowel and Bladder assessment dated 4/3/2022, the assessment indicated Resident 84 was a poor candidate for toileting schedule for retraining. During a review of Resident 84's Physician's Order dated 4/3/2022, the order indicated the resident may have an abdominal binder and mittens to prevent the pulling of the G-tube. During a review of Resident 84's Admission Progress Nursing Note dated 4/3/2022 at 8:16 p.m., the admission nursing note indicated an abdominal binder and bilateral mittens was in placed to prevent the resident from pulling out the G-tube. During a review of Resident 84's CNA notes from 4/3/2022 to 4/5/2022, the notes indicated the mittens were not included in monitoring from 7:00 a.m. to 3:00 p.m. (AM shift), from 3:00 p.m. to 11:00 p.m. (PM shift) and from 11:00 p.m. to 7:00 a.m. (Night Shift). During a review of Resident 84's Progress Nursing Notes from 4/3/2022 to 4/5/2022, the notes indicated that there was no documentation the resident's bilateral mittens had been released every 2 hours. There was no skin assessment and monitoring documented. During an interview with the Director of Rehabilitation (DOR) on 4/4/2022 at 11:00 a.m., DOR stated if residents did not move a lot the muscles tighten, so, staff want residents to move as much as possible. DOR stated Resident 84 was totally dependent on mobility per joint mobility assessment (JMA) done by Physical Therapy (PT) on 4/4/2022. During an interview with the DON on 4/6/2022 at 2:25 p.m., the DON stated all restraints were initiated because of the resident's change of condition. DON stated that prior to initiation of any restraints, an Interdisciplinary Team meeting ([IDT] group of different disciplines working together towards a common goal of a resident) should be conducted to discuss the resident's plan of care during the resident's stay in the facility. DON stated a valid consent for any restraint was required prior to use. DON confirmed Resident 84's IDT meeting was not done, and the resident did not have an informed consent for the use of the bilateral mittens. The DON stated Resident 84's abdominal binder was the least restrictive measure to prevent the resident pulling out the G-tube and did not need the bilateral mittens. The DON stated that all restraints should be care planned, assessed and monitored for skin breakdown. b. During a review of the Resident 36's Admission Record, the admission record indicated the resident was admitted to the facility on 12/17/2019. Resident 36's diagnoses included low back pain, chronic obstructive pulmonary disease [(COPD) group of lung diseases that block airflow and make it difficult to breathe], and hypertension (high blood pressure). During a review of Resident 36's MDS, dated 2/7/2022, the MDS indicated Resident 36 had clear speech, was able to make himself understood and was able to understand others. The MDS indicated Resident 36 required limited assistance with one person assist with activities of daily living ([ADLs] self-care activities performed daily) such as bed mobility, dressing, transfer, personal hygiene, walking in the room and corridor, locomotion on and off the unit (how residents move to and return off unit locations), toilet use, and required supervision with eating. During a review of Resident 36's Annual History and Physical (H/P) dated 2/27/2022, the H/P indicated Resident 36 was able to make needs known but could not make medical decisions. During a review of Resident 36's "Physical restraints or prolonged use of a device pelvic restraint in wheelchair" document, dated 1/18/2022, indicated consent obtained from the surrogate decision maker/conservator was signed by the resident's physician. During a review of Resident 36's care plan titled, "Safety Compromised related to Falls manifested by poor safety awareness, behavior problems, medical problems, possible side effects to restraints," dated 11/26/2021 and revised 1/18/2022, the care plan indicated Resident 36 may have pelvic restraints in wheelchair due to poor safety awareness secondary to dementia. During a review of the Resident's 36's Care Conference note dated 2/15/2022, there was no mention of the use of physical restraints during the IDT meeting. During a review of Resident 36's Physical Therapy Treatment note dated 12/3/2022, the note indicated Resident 36 was able to ambulate (walk) 50 feet with two turns with partial or moderate assistance. The note indicated Resident 36 had a history of three prior falls and was afraid of falling again. During a review of Resident 36's Joint Mobility Assessment dated 11/18/2021, the JMA indicated that Resident 36 could move his upper extremities and lower extremities within functional limit. During an observation on 4/4/2022 at 10:35 a.m., Resident 36 was observed wheeling himself in the hallway with a pelvic restraint double tied at the back of the resident's wheelchair. During a concurrent observation and interview on 4/6/2022 at 1:44 p.m., CNA 15 was observed demonstrating how to remove Resident 36's pelvic restraint. The restraint ties were observed to be inserted three times in the wheelchair bar. CNA 15 was observed having difficulty removing the restraint. CNA 15 stated she needed to make sure the ties were looped around the bar of the wheelchair because Resident 36 attempted to remove it and get up unassisted. CNA 15 stated that Resident 36 was continent (ability to control) of both bowel and bladder function and needed staff to release or remove the pelvic restraint when the resident needed to use the bathroom. During an interview with Resident 36 on 4/6/2022 at 1:55p.m., Resident 36 stated he could not independently go to the bathroom because of the restraint. Resident 36 stated the restraint was tied behind the wheelchair so he could not reach it. Resident 36 stated he could use the bathroom if he was not tied to the wheelchair. Resident 36 stated he feels humiliated going to the dining room with the restraint. During a review of Resident 36's Physician's Order dated 1/18/2022, the order indicated Resident 36 may have pelvic restraint in wheelchair due to poor safety awareness secondary to dementia. c. During a review of the Resident 345's Admission Record, the admission record indicated the resident was admitted to the facility on 3/9/2022. Resident 345's diagnoses included anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and bipolar disorder ( a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). During a review of Resident 345's Baseline Care Plan dated 3/29/2022, the care plan indicated Resident 345 was verbally confused with adequate vision and hearing. The care plan indicated Resident 345 had a lap buddy restraint. During an initial tour of the facility on 4/4/2022 at 8:35 a.m., Resident 345 was observed with a lap buddy restraint and was attempting to tell CNA 12 to remove the restraint. During an interview with CNA 12 on 4/4/2022 at 12:35 p.m., CNA 12 stated Resident 345 was continent of both bowel and bladder function and needed help removing the restraint. CNA 12 stated the restraint was applied for the resident's safety because Resident 345 tried to get up unassisted. CNA 12 stated the discoloration noted to Resident's 345's forehead was from a fall incident. CNA 12 stated Resident 345 was new to the facility and was not that familiar with Residents 345's behaviors. CNA 12 stated at the beginning of each shift, the charge nurse or supervisor would inform staff about new admissions. During a review of Resident 345's Consent for Chemical/Physical Restraint dated 4/1/2022, there was no physician signature indicating the consent was obtained from the resident's surrogate/decision maker. During a review of Resident 345's medical records, there was no physical restraint assessment, or documentation indicating a least restrictive device was offered, attempted and unsuccessful. During a review of Resident 345's Physician's Telephone Order dated 4/1/2022, the order indicated to apply a lap buddy due to poor safety awareness related to dementia. During a review of Resident 345's Joint Mobility Assessment dated 3/30/2022, the assessment indicated that Resident 345's upper and lower extremities were within functional limit per the occupational therapist (OT). The assessment indicated Resident 345 was functioning at high level of independence but utilizing a merry walker (considered a restraint if the resident was unable to open and close the front gate and caregiver assistance must be provided to release the resident form the device). During a review of Resident 345's Nursing Note dated 4/1/2022 at 9 p.m., the note indicated may have lap buddy due to poor safety awareness related to dementia, informed consent obtained by nurse from the responsible party. During a concurrent observation and interview with CNA 6 and Resident 345 on 4/5/2022 at 6:27 a.m., CNA 6 stated Resident 345 was unable to remove the lap buddy. CNA 6 stated she made sure the restraint was applied properly and correctly so Resident 345 could not easily remove it. Resident 345 was asked to demonstrate the removal of restraint and was observed unable to remove the restraint. Resident 345 verbalized the restraint was hard to remove. d. During a review of Resident 80's Admission Record, the admission record indicated the resident was admitted to the facility on 2/15/2022. Resident 80's diagnoses included hemiplegia (paralysis [inability to move] of one side of the body) affecting the right side, encephalopathy (damage or disease affecting the brain), valve disorder (heart problem), lack of coordination, dementia, and anemia (condition in which not enough healthy red blood cells to deliver oxygen to the body tissues). According to the admission record Resident 80's family member (FM 1 and FM 2) were indicated as the resident's emergency contacts. During a review of Resident 80's MDS, dated 2/22/2022, the MDS indicated Resident 80 usually expressed ideas and wants and usually understood verbal content. The MDS indicated Resident 80 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 80 required extensive assistance with eating, bed mobility, walking, and was totally dependent with transfer, toilet use, personal hygiene, and dressing. During a review of Resident 80's Physician's orders dated 2/15/2022, the orders indicated Resident 80 may have a pelvic restraint (seat belt assembly intended to retrain movement of the pelvis [lower part of the trunk between