Health inspection·February 7, 2024

California Code of Regulations, Title 22, § 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. (e) No restraints with locking devices shall be used or available for use in a skilled nursing facility. (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. California Code of Regulations, Title 22, Section 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. California Code of Regulations, Title 22, § 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. Code of Federal Regulations, Title 42, §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. On 12/21/2023 at 6:20 a.m., The California Department of Public Health (CDPH, the Department) conducted an unannounced visit to the facility to investigate a complaint regarding an abuse allegation. As a result of the investigation, the Department determined the facility failed to ensure Resident 3 remained free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to a resident’s body, cannot be easily removed by a resident, and restricts the resident’s freedom of movement or access to their body) for the use of convenience by failing to: Ensure Certified Nurse Assistant (CNA) 1 did not restrain Resident 3 during patient care (prevention, treatment, and management if illness and preservation of physical and mental well-being through services offered by health professionals), witnessed by CNA 3, CNA 4, and Licensed Vocational Nurse (LVN) 2 . As a result, Resident 3 was restrained by CNA 1 during patient care. These failures had the potential for Resident 3 to suffer psychosocial (mental, emotional, social, and spiritual effects) harm, physical injury, and/or death. Findings: A review of Resident 3’s Admission Record (AR)indicated the facility admitted a 53-year-old male to the facility on 1/26/2023, with diagnoses of tracheostomy (incision made in the windpipe to relieve an obstruction to breathing) and unspecified psychosis (severe mental condition in which thought, and emotions are so affected that contact is lost with external reality). A review of Resident 3’s Minimum data Set (MDS- a standardized resident assessment and care screening tool), dated 10/10/2023, indicated Resident 3 had severe cognitive (ability to think, reason, and function) impairment. The MDS indicated Resident 3 had physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing, abuse others sexually). The MDS indicated Resident 3 was dependent for eating, oral hygiene, toileting hygiene, showering/bathing, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. The activity for walking in room or corridor (hall) or locomotion on or off unit did not occur. During an interview on 12/21/2023 at 6:30 am with CNA 1, CNA 1 stated all residents who live in the sub-acute unit (level of care needed by a resident who does not require acute hospital care but requires more intensive licensed skilled nursing care) were “dead weight.” CNA 1 stated dead weight meant residents (in general) were incapable of activities of daily living (ADL- the tasks of everyday life fundamental to caring for oneself) such as “changing an incontinent brief, changing bedding, and repositioning themselves.” CNA 1 stated CNA 1 had to “exert all (CNA 1’s) power and strength” when providing patient care. CNA 1 stated CNA 1 did not need to ask other staff for assistance with patient care because CNA 1 was “strong”. During an interview on 12/21/2023 at 6:54 am with CNA 3, CNA 3 stated CNA 3 worked with CNA 1 two shifts a week for the past two years. CNA 3 stated CNA 1 did not ask CNA 3 for help when providing patient care to dependent residents (in general). During a telephone interview on 12/21/2023 at 1:02 pm with CNA 3, CNA 3 stated “two to three months ago” (unable to recall specific date), CNA 3 witnessed Resident 3 was “tied up with two socks” while Resident 3 was in bed. CNA 3 stated CNA 1 used one sock to tie around each of Resident 3’s wrists and used a second sock to anchor the first sock to the left and right side of Resident 3’s bedrails (rail at the head, foot, or side of a bed). During an interview on 12/21/2023 at 11:58 am with CNA 4, CNA 4 stated during an incident about “two to three months ago” (unable to recall specific date), CNA 4 witnessed Resident 3 right side lying (lying on the right side), and “tied up” to the bedrail. CNA 4 stated Resident 3 could not move Resident 3’s upper body while CNA 1 provided incontinence care. CNA 4 stated CNA 4 told CNA 1 it was “not okay” to tie up Resident 3 because it was “abuse in the form of restraints.” During an interview on 12/21/2023 at 1:45 pm, with CNA 4, CNA 4 stated when CNA 4 witnessed CNA 1 tie up Resident 3 during another incident “two to three months ago” (unable to recall specific date), CNA 1 rolled a flat sheet around Resident 3’s arms once, then wrapped the sheet around Resident 3’s bedrail and tied a knot. CNA 4 stated the knot was so tight there was “no wiggle room” for Resident 3. During a telephone interview on 12/21/2023 at 3:11 pm, with LVN 2, LVN 2 stated “during the last six months” (unable to recall specific dates), LVN 2 witnessed Resident 3 lying in bed “tied up” with a flat sheet wrapped around Resident 3’s arms and wrists during incontinence care. LVN 2 stated Resident 3’s sheet was tucked between Resident 3’s mattress and bedframe so Resident 3’s upper body and arms could not move. LVN 2 stated this was a form of restraint. LVN 2 stated CNA 1 admitted every time that CNA 1 provided incontinence care, CNA 1 tied up Resident 3. LVN 2 stated CNA 1 explained that CNA 1 tied the sheet around Resident 3 so Resident 3 could not move or punch (hit) CNA 1. LVN 2 stated LVN 2 told CNA 1 that CNA 1 could not tie up Resident 3. LVN 2 stated LVN 2 told CNA 1 that it was a form of restraint and abuse. During an interview on 12/21/2023 at 4:16 pm with the DON, the DON stated socks or bed sheets were not allowed to be used in the facility to restrain residents (in general). The DON stated restraining or “tying up” residents (in general) with socks or bed sheets could affect a resident’s ability to move. The DON stated “tying up” residents with socks or bed sheets to restrain residents (in general) could cause residents to become emotionally upset and afraid all staff were going to restrain them when providing patient care. The DON stated this could lead to psychological harm. The DON stated a resident could get injured or die if restraints are used without a physician’s order. The DON stated Resident 3 did not have a physical restraints order. During a review of the facility’s PP titled, “Restraints,” revised 11/1/2017, the PP indicated a physical restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body. The facility will ensure that restraints will not be imposed for purposes of discipline or convenience. The PP indicated there must be a physician’s order for the use of the restraint which includes medical symptoms for use, frequency of use, type of restraint, release protocols, and plan for reduction, when applicable. During a review of the facility’s policy and procedure (PP) titled, “Resident Rights,” revised 5/1/2023, the PP indicated the purpose was to promote and protect the rights of all residents at the facility. The PP indicate the facility must treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life, recognizing each resident’s individuality. As a result of the investigation, the Department determined the facility failed to ensure Resident 3 remained free from physical restraints for the use of convenience by failing to: Ensure CNA 1 did not restrain Resident 3 during patient care witnessed by CNA 3, CNA 4, and LVN 2. As a result, Resident 3 was restrained by CNA 1 during patient and had the potential for Resident 3 to suffer psychosocial harm, physical injury, and/or death. The above violations had a direct or immediate relationship to the health, safety, or security of Resident 3.