Health inspection·February 15, 2024

Code of Federal Regulations, Title 42, Section §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. California Code of Regulations, Title 22, Section § 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 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. On 12/26/24 at 10:30 am. the California Department of Public Health conducted an unannounced recertification survey. As a result of the investigation, the Department determined the facility failed to ensure the use of soft mitten restraints (large glove that covers the hand used to restrict freedom of movement or access to one's body) was necessary and in accordance with the facility's policy and procedure titled, "Restraints," for Resident 12 by failing to: 1. Attempt to use the least restrictive alternative prior to the use of soft mitten restraints. 2. Notify Resident 12's physician and obtain an order for the use of soft mitten restraints. 3. Monitor Resident 12 and document the use of soft mitten restraints. As a result of these failures, the facility violated Resident 12's right to be free from unnecessary use of physical restraint and the right to be treated with respect and dignity. A review of Resident 12's Admission Record (AR) indicated the facility admitted Resident 12, a 100-year-old female on 6/11/21, and readmitted Resident 12 to the facility on 12/22/23, with diagnoses that included Alzheimer's disease (disease causing memory loss and other mental functions), lack of coordination, and fracture (broken bone) of the neck of the left femur (thigh bone). A review of Resident 12's History and Physical (H&P), dated 1/9/23, indicated Resident 12 did not have the capacity to understand and make decisions. A review of Resident 12's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 10/12/23, indicated Resident 12 was cognitively impaired. The MDS indicated the resident was dependent (helper does all effort) for sit to stand, chair to bed transfer, toilet transfer, shower, lower body dressing, and putting on/off footwear. During an observation on 12/26/23 at 11:30 am, Resident 12 was sitting on her bed with nasal cannula (NC, a device used to deliver oxygen) on the resident's left nostril, heparin lock (Hep-Lock, a catheter placed in a vein to administer medication or fluid) on the left upper arm and generalized small scabs on both arms. There were two (2) soft mitten restraints on Resident 12's bedside dresser. During an observation on 12/27/23 at 11:14 am, inside Resident 12's room, a pair of soft mitten restraints was noted inside the top drawer of Resident 12's bedside dresser. During a concurrent interview and record review on 12/28/23 at 10:19 am with the Assistant Director of Nursing (ADON), Resident 12's paper and electronic chart were reviewed. The ADON stated, Resident 12 was not combative. The ADON stated, soft mittens were considered a physical restraint. The ADON stated any restraint apparatus should not be at any resident's bedside because the staff may use the restraint (mittens) on the resident. The ADON stated, prior to the application of a restraint on any resident, the following steps needed to be completed: physical assessment of the resident, obtaining a physician's order to apply the restraint, obtaining consent from the resident's responsible party, and monitoring the resident every two hours for any pain or complications. ADON stated, there were no documentation in Resident 12's chart pertaining to the use of the restraint. The ADON stated, there was no attempt to use the least restrictive measure prior to applying the mittens, no physician order documented to use soft mitten restraints, and no monitoring for the use of soft mitten restraints. During an interview with on 12/28/23 at 10:43 am with Restorative Nursing Assistant 1 (RNA 1, provides rehabilitative care), RNA 1 stated Resident 12 had a habit of removing her NC and clothes, but was not combative. RNA 1 stated, during RNA 1's morning rounds on 12/25/23, RNA 1 observed Resident 12 wearing soft mitten restraints on both hands. During a concurrent observation and interview on 12/28/23 at 10:48 am with Certified Nurse Assistant 8 (CNA 8) in Resident 12's bedside, 2 soft mittens were observed inside the resident's bedside dresser. CNA 8 stated, Resident 12 had frail and fragile skin and constantly removed Resident 1w's NC. CNA 8 stated, she observed Resident 12 wearing the soft mittens on 12/24/23. CNA 8 stated, she removed the soft mittens when she fed Resident 12's lunch. CNA 8 stated after lunch, she applied the soft mittens back on Resident 12. CNA 8 stated, no one informed her about removing or putting on soft mittens for Resident 12. During a telephone interview on 12/28/23 at 11:20 am with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 12 had fragile skin and a habit of picking her nose that sometimes led to bleeding. LVN 1 stated, on 12/24/23, he observed Resident 12 with soft mittens on both hands. LVN 1 stated, he did not remove the soft mittens from Resident 12's hands. LVN 1 stated, he did not inform Resident 12's physician regarding the use of soft mittens and did not obtain a physician order. LVN 1 stated, Resident 12's physician should have been notified regarding the use of soft mittens because it could be a form of restraints. LVN 1 stated the mittens could prevent Resident 12's freedom on whatever she wanted to do with her hands. LVN 1 stated, soft mittens were a form of restraints, and the use of restraints should be documented and monitored to ensure the soft mittens were safe for Resident 12. During an interview on 12/28/23 at 11:37 am with RNA 2, RNA 2 stated Resident 12 had soft mittens on both hands on 12/25/23. RNA 2 stated, soft mittens were "not a form" of restraints because they were not tied to the bed and Resident 12's hands were free to move. During a concurrent interview and record review on 12/28/23 at 1:42 pm with the Director of Nursing (DON), Resident 12's paper and electronic chart were reviewed. The DON stated soft mittens were a form of physical restraints. The DON stated, prior to applying soft mittens, the nurses must attempt to use the least restrictive measures (place resident closer to nurse station, family involvement, extra activity) for safety and to determine the root cause of Resident 12's behavior. The DON stated, Resident 12's physician needed to be informed to discuss the risk and benefits of the use of soft mittens. During an interview on 12/28/23 at 3:43 pm with the Director of Staff Development (DSD), the DSD stated Resident 12's paper and electronic chart did not indicate a restraint assessment was done and documented for Resident 12. The DSD stated, it was important to assess the resident for the use of physical restraint to ensure the necessary use of the restraint because restraints could physically hurt Resident 12 and could be used as a form of abuse. The DSD stated a physician order was required for the use of restraints because restraints could be a form of abuse. During a concurrent observation and interview on 12/29/23 at 2:38 pm with LVN 8, two soft mitten restraints were observed on the top drawer of Resident 12's bedside dresser. LVN 8 stated, a physician order, responsible party consent, care plan, and constant monitoring were needed prior to applying any form of restraints on the resident. A review of the facility's policy and procedure (P&P) titled, "Restraints," dated 1/1/12, the P&P indicated, to ensure all restraints are used properly and only necessary on residents at the facility. The P&P indicated facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. If restraints are used, the facility complies with all applicable laws and regulations. The least restrictive alternatives are used for the last amount of time, and only under carefully monitored circumstances. The P&P indicated before any type of restraint is used, the licensed nurse will verify that the informed consent was obtained from the resident and has been documented in the resident's medical record. The licensed nurse will obtain an attending physician's order for use of restraints. The order must be specific to the individual resident and must include the following information: the presence of a medical symptom that requires the use of restraint; the type of restraint used; when the restraint is to be used and the period of time the restring is to be used. The P&P indicated physical restraint/device assessment will be completed upon admission, quarterly and when a restraint occurs. The licensed nurse will keep detailed records of restraint episodes in the resident's medical record, noting type of restraint used; where the restraint was applied; name of the individual applying the restraint; efforts to release resident (at least every 2 hours); observations (at least every 15 minutes; resident activities during the restraint period; and nursing interventions undertaken during the restraint time frame. As a result of the investigation, the Department determined the facility failed to ensure the use of soft mitten restraints was necessary and in accordance with the facility's policy and procedure titled, "Restraints," for Resident 12 by failing to: 1. Attempt to use the least restrictive alternative prior to the use of soft mitten restraints. 2. Notify Resident 12's physician and obtain an order for the use of soft mitten restraints. 3. Monitor Resident 12 and document the use of soft mitten restraints. As a result of these failures, the facility violated Resident 12's right to be free from unnecessary use of physical restraint and the right to be treated with respect and dignity. The above violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 12.