Other·July 13, 2022

F604 CFR § 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. T22 § 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. On 4/19/2022, an unannounced visit was made to the facility to investigate a Facility-Reported Incident (FRI) regarding patient abuse. The facility failed to ensure Patient 1 was free from any unauthorized physical restraints (device that restricts the resident's freedom to and ability to move about and cannot be easily removed or eliminated by the resident) while in bed. Certified Nursing Assistant 1 (CNA 1) and CNA 2 restricted Patient 1’s movement on 4/7/2022 until 4/8/2022 by placing a bedsheet “tightly” over Patient 1’s chest, with both of the bedsheet’s upper corners tied to the side rails of the bed and sides tucked in “tightly” under the mattress. This failure violated Patient 1's rights and had the potential to cause physical and/or psychological harm to Patient 1. A review of Patient 1’s Admission Record indicated this 86 years old female patient was initially admitted to the facility on 3/30/2022 with diagnoses including dementia (loss of memory, language, problem-solving, and other thinking abilities severe enough to interfere with daily life) and hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following a stroke. A review of the Patient 1’s Minimum Data Sheet (MDS, a standardized resident screening and care-planning tool), dated 4/6/2022, indicated the patient had severe impairment in cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Patient 1 required extensive assistance with bed mobility and was totally dependent on staff with dressing, toileting, and personal hygiene. A review of Patient 1’s SBAR Communication Form (Situation-Background-Assessment-Recommendation provides a framework for communication between members of the health care team about a resident's condition) and Progress Note, dated 4/8/2022, indicated the Treatment Nurse 1 (TN 1) alerted Registered Nurse 1 (RN 1) and Licensed Vocational Nurse 1 (LVN 1) on 4/8/2022 at 8 a.m. that Patient 1 was, “noted with bedsheet tightly tucked with both upper sides of bedsheet tied to upper side rails. Lower portion of bedsheet tightly tucked under mattress – resident unable to move – bed in lowest position. Unauthorized restraint was immediately removed.” During an interview on 4/19/2022 at 11:24 a.m., the Director of Staff Development (DSD) stated during the teleconference interview on 4/8/2022 of CNA 1 by the DSD, Administrator, and the Director of Nursing (DON), CNA 1 admitted that on 4/7/2022 at 3 p.m. -11 p.m. shift, she tied the bedsheet corners to the side rails to prevent Patient 1 from taking off her clothes and her incontinent brief and from trying to get out of bed (OOB). In addition to that, the DSD stated during the teleconference interview on 4/8/2022, CNA 2 stated that on 4/7/2022 at 11 p.m. -7 a.m. shift, CNA 2 saw and left Patient 1 in the same condition, because she, “did not think anything of it,” because Patient 1 was, “not in distress.” The DSD stated both CNA 1 and CNA 2 were not allowed to come back to work after the incident and were terminated by the facility after the investigation. During an observation on 4/19/2022 at 12:15 p.m., Patient 1 was lying in bed in her room, awake and alert, calm but did not answer when asked questions. Patient 1 was observed with no evidence of pain, bleeding, or bruising. Patient 1 was partially covered by a bedsheet and blanket, but she was able to move her right arm and right legs without difficulty. The left arm and left leg were observed with very limited movement. During a telephone interview on 4/20/2022 at 10:07 a.m., CNA 2 stated upon the start of her 11 p.m.– 7 a.m. shift on 4/8/2022, CNA 2 found Patient 1’s bedsheet covering the resident with both upper ends tied to the side rails. CNA 2 stated she assumed this was the previous shift’s intervention because Patient 1 had a history of taking off her clothes and incontinence brief. CNA 2 stated she left Patient 1’s bedsheet in the same condition as it helped prevent Patient 1 from taking off her incontinence brief during her shift. During a telephone interview on 4/20/2022 at 10:38 a.m., CNA 1 stated on 4/7/2022 at around 9 p.m., she tied the top corners of the bedsheet to the side rails to prevent Patient 1 from sliding down the bed. CNA 1 stated it was her first time to be assigned to Patient 1 and during that 3 p.m.– 11 shift, Patient 1 took off her incontinence brief twice and was found sliding down the bed. CNA 1 stated she knew she was not supposed to restrain Patient 1, but she forgot to untie the bedsheet from the side rails before her shift ended as she was assisting other residents. During a telephone interview on 4/20/2022 at 11:25 a.m., TN 1 stated on 4/8/2022 before 8 a.m., she entered Patient 1’s room and found Patient 1 with her bedsheet tucked in tight under the mattress on both sides. TN 1 stated upon further inspection, she saw two upper corners of the bedsheet tied onto both upper side rails. TN 1 stated Patient 1 could not move her body, except her right upper extremity. TN 1 stated she immediately notified RN 1 about the incident. During a telephone interview on 4/20/2022 at 1:56 p.m., RN 1 stated upon being notified by TN 1, she immediately assessed Patient 1’s condition. RN 1 stated Patient 1 was found lying in bed, with the white bedsheet very tight across Patient 1’s chest and each upper corner tied to the side rails. RN 1 stated the bedsheet sides were also tucked tightly under the mattress. RN 1 stated they untied and untucked the bedsheet and immediately conducted a head-to-toe assessment on Patient 1. RN 1 stated Patient 1 was not observed with any injuries after the assessment. During a telephone interview on 4/25/2022 at 10:46 a.m., the DON stated per staff interviews, Patient 1 exhibited new behaviors of sliding down the bed and taking off her gown on the day that the unauthorized restraint was initiated. The DON stated it was unacceptable to use the bedsheet as a restraint to restrict Patient 1’s movement due to a potential to cause injury to Patient 1. The DON stated if Patient 1 was sliding down the bed, the rehabilitation department could have been consulted to evaluate Patient 1’s bed mobility and recommend interventions. The DON stated if the resident was noted taking off her clothes, the primary care provider could have been notified to obtain orders, such as laboratory tests, to determine the cause of further confusion. A concurrent review of Patient 1’s care plan on Impaired Activities of Daily Living (ADL) functions, initiated on 3/31/2022, indicated the following interventions: a. Assist in changing position at least every 2 hours or as needed b. Visual checks every 2 hours to timely assist resident with needed ADLs and to ensure safety c. Provide a safe environment and emphasize fall precaution d. Physical therapy (PT)/Occupational therapy (OT) as ordered to improve ADL functions e. Encourage resident’s independence with minor assistance and praise for all effort A review of the facility’s policy and procedures titled “Use of Restraints,” dated 4/2017, indicated restraints must only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. The policy indicated restraints must only be used to treat the resident’s medical symptom/s and never for discipline or staff convenience, or for the prevention of falls. The policy and procedure indicated that practices that inappropriately utilize equipment to prevent resident mobility, such as tucking sheets tightly that a bed-bound resident could not move, would be considered a restraint and would not be permitted. The policy indicated that prior to placing a resident in restraints, there must be a pre-restraining assessment and review to determine the need for restraints and determine possible underlying causes of the problematic medical symptom and if there were less restrictive interventions. The facility failed to ensure Patient 1 was free from any unauthorized physical restraints while in bed. Certified Nursing Assistant 1 (CNA 1) and CNA 2 restricted Patient 1’s movement on 4/7/2022 until 4/8/2022 by placing a bedsheet “tightly” over her chest, with both of the bedsheet’s upper corners tied to the side rails of the bed and sides tucked in “tightly” under the mattress. The facility failed to ensure Patient 1 was free from any unauthorized physical restraints while in bed. Certified Nursing Assistant 1 (CNA 1) and CNA 2 restricted Patient 1’s movement on 4/7/2022 until 4/8/2022 by placing a bedsheet “tightly” over her chest, with both of the bedsheet’s upper corners tied to the side rails of the bed and sides tucked in “tightly” under the mattress. As a result, this failure violated Patient 1's rights and had the potential to cause physical and/or psychological harm to Patient 1. This violation jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 1.