Other·July 1, 2021

F700 §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. T22 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. T22 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 5/14/2021 at 12:26 pm, the Department of Public Health (Department) made an unannounced visit to the facility to investigate a facility reported incident regarding quality of care and resident safety. The facility failed to implement interventions to provide a safe environment for 5 of 5 sampled residents (Residents 1, 2, 3, 4, and 5), as indicated in the facility’s Bed Rails (adjustable metal or rigid plastic bars that attach to the bed) Proper Use policy and procedure by failing to: 1. Identify environmental hazards (elements of the resident environment that have the potential to cause injury or illness) and have interventions in place. Environmental hazards included the risk of entrapment (an event in which a resident is caught, trapped, or entangled in a space) caused by the use of bed rails for Resident 1 who had tremors (an involuntary quivering movement) and a tendency to slide down from the Low Air Loss mattress (LAL, mattress that operates using a blower based pump that was designed to circulate a constant flow of air). The facility failed to have interventions such as measurement of bed dimensions in accordance to the Resident 1’s size and weight to avoid entrapment between bed rails and mattress for Resident 1. 2. Assess Residents 1, 2, 3, 4, and 5 for risk of entrapment caused by the bed rails prior to use and to have bed dimensions measured based on each resident’s size and weight for the use of bed rails in accordance to the manufacturer’s recommendations and specifications to avoid accidents such as entrapment between bed rails and mattress. As a result, on 5/12/2021 at 10:55 pm, Resident 1 was found by Certified Nursing Assistant 1 (CNA 1) in bed unresponsive, with no pulse, no respirations (not breathing), lying on the resident’s right side with her head stuck between the padded bed rails and LAL mattress. Resident 1 was transferred to the general acute care hospital 1 (GACH 1) via 9-1-1 (emergency services). Resident 1 subsequently died on 5/13/2021 at 6:20 pm. Resident 1 had anoxic brain injury (caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation). These deficient practices placed Residents 1, 2, 3, 4, and 5 at risk for entrapment that could cause serious harm, injury, or death, and resulted in the serious harm and death of Resident 1. 1. A review of Resident 1’s Admission Record indicated the facility admitted a seventy-four- year-old on 6/20/2017, with diagnoses of Parkinson’s disease (disorder of the central nervous system that affects movement) and dementia (loss of memory and other mental abilities severe enough to interfere with daily life). A review of Resident 1’s Side Rail Utilization Assessment dated 6/20/2017, indicated for the resident to have two half side rails (half of the length of the bed, could be the sides of the head of bed or foot of the bed), as an enabler to promote independence with positioning and bed mobility. A review of Resident 1’s Care Plan (CP) for the use of padded bed rails initiated on 6/29/2018, indicated for the resident to have two half bed rails (no size identified) for bed mobility and to assist with positioning from supine (lying face upward) to sitting. The CP indicated the goal was for the resident not to have any injuries and the nursing interventions were to monitor safety during care. A review of Resident 1’s Order Summary Report dated 2/24/2019 indicated the resident may have an “air mattress.” A review of Resident 1’s CP dated 5/30/2019, indicated for the resident to have two half bed rails up (unidentified size) per physician order and observe for injury or entrapment related to bed rail use. A review of Resident 1’s Order Summary Report dated 3/2/2021, indicated for Resident 1 to have two side rails (no size identified, pertaining to two half bed rails) up while in bed for bed mobility. A review of Resident 1’s Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 3/31/2021, indicated the resident had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making and required extensive assistance for bed mobility (ability to move easily in bed), eating, and personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness). A review of Resident 1’s Progress Notes dated 5/12/2021, and timed at 11 pm, indicated that at 10pm a CNA (unidentified) pulled Resident 1 up in bed because Resident 1 kept sliding down the bed due to tremors. The notes indicated two CNAs (unidentified) entered Resident 1’s room at 10:55 pm and found Resident 1 unresponsive with the resident’s head wedged between the padded bed rails and LAL mattress on the right side facing the window. The notes indicated Resident 1 did not have a pulse and no respirations. Cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) was started. The notes indicated an RN supervisor (unidentified) called 9-1-1. The notes indicated emergency services arrived at the facility at 11:17 pm, and Resident 1 was taken to GACH 1. A review of Resident 1’s Prehospital Care Report dated 5/12/2021 and timed at 11:02 pm, indicated emergency services arrived at the facility on 5/12/2021 at 11:13 pm. The resident was in cardiac arrest (the abrupt loss of heart function, breathing and consciousness [being awake]). A review of Resident 1’s Death Summary at GACH 1, dated 5/14/2021 and timed at 8:56 am, indicated the resident presented to the emergency department on 5/12/2021 after the resident was found unresponsive at the facility. The summary indicated the resident was suspected to have an estimated downtime (unresponsive) approximately twenty to thirty minutes. The summary indicated Resident 1’s Computed Tomography (CT, scan allows doctors to see inside the body) indicated Resident 1 had cerebral edema (brain swelling, a potentially life-threatening condition with fluid development in the brain) suggesting anoxic brain injury. The summary indicated the resident died on 5/13/2021 at 6:20 pm from respiratory failure a serious condition that develops when the lungs can't get enough oxygen into the blood. A review of Resident 1’s Certificate of Death indicated Resident 1’s date of death was 5/13/2021 at 6:06pm, and Resident 1’s immediate cause of death was anoxic encephalopathy (brain damage due to lack of oxygen?). During an interview on 5/14/2021 at 3:10 pm with the facility’s Director of Nursing (DON) and a review of Resident 1’s Progress Notes dated 5/12/2021 at 11:41 pm, the Progress Notes indicated CNA 1 and CNA 2 found Resident 1 unresponsive with the resident’s head wedged between padded side rails and LAL mattress on her right facing the window. The DON stated Resident 1 was found unresponsive with her head wedged between the LAL mattress and bed rails on 5/12/2021 at 10:55 pm by the two CNAs. During an interview on 5/14/2021 at 3:55 pm, CNA 1 stated she found Resident 1 unresponsive, with no pulse, not breathing, and saw Resident 1’s head hanging by the top edge of the bed rails facing towards the window (right side of the bed) on 5/12/2021 at 10:55 pm. CNA 1 stated Resident 1’s upper body was in between the padded bed rails and LAL mattress and her legs were hanging on the right side of the bed all the way to the floor. CNA 1 stated she was familiar with Resident 1 having increased tremors especially when the resident was anxious (experiencing worry, unease, or nervousness) and she tended to slide down or on the side of the LAL mattress. During an interview on 5/14/2021 at 6:38 pm the Maintenance 1 stated he did not have individual bed dimension measurements for Resident 1. Maintenance 1 stated it was important to have the resident’s bed dimensions measured according to the resident’s size and weight as recommended by the bed manufacturer, so residents could be safe while in bed and to avoid accidents of entrapment between the bed rails and the mattress. During an interview with the DON on 5/14/2021 at 6:40 pm, and a review of the facility’s Side Rails, Proper Use of Policies and Procedures with effective date of 4/23/2021, the DON stated the policy indicated to meet patient’s needs for safety for bed rail use, to monitor the resident frequently, use a proper size mattress and reduce the gaps between the mattress and side rails. The policy also indicated the use of bed rails required ongoing patient evaluation and monitoring to optimize bed safety. DON stated the bed rail use was considered a hazard (potential source of harm) for the resident’s safety and that the facility failed to intervene to avoid harm to Resident 1 because bed dimensions were not measured according to the size and weight of Resident 1 on 3/24/2021 (pertaining to the Bed Rail Use and Entrapment Risk Evaluation form). DON stated the Bed Rail Use and Entrapment Risk Evaluation was not done the correct way which was to have the appropriate bed dimensions in accordance with the resident’s size and weight to minimize the gap in between the bed rails and mattress. During a telephone interview with Licensed Vocational Nurse 2 (LVN 2) on 5/15/2021 at 10:52 am, LVN 2 stated he was the charge nurse when Resident 1 was transferred to GACH 1 on 5/12/2021. LVN 2 stated that on 5/12/2021 during the change of shift rounds between 10:55 pm and 11 pm, Resident 1’s emergency call light was activated. LVN 2 stated he saw Resident 1 lying on the right side, facing towards the window, and the resident’s body wedged in between the padded bed rails and LAL mattress. LVN 2 stated Resident 1 was not responding, not breathing, and had no pulse. LVN 2 stated he started Cardiopulmonary Resuscitation CPR while waiting for 9-1-1 to arrive. LVN 2 stated Resident 1 was transferred to GACH 1 on 5/12/2021 at 11:17 pm. During a telephone interview with CNA 2 on 5/15/2021 at 11:17 am, CNA 2 stated she went to Resident 1’s room with CNA 1 on 5/12/2021 at 10:55 pm. CNA 2 stated she saw Resident 1 up against the side of the bed rails. CNA 2 stated she was not sure where Resident 1’s head was but it was facing towards the window on the right side. CNA 2 stated the resident’s upper body was facing the bed rails which was stuck in between the bed rails and the LAL mattress. During a telephone interview on 5/16/2021 at 9:52 am, Registered Nurse 1 (RN 1) stated she was the RN supervisor working on 5/12/2021 when the emergency call light went on for Resident 1. RN 1 stated she saw Resident 1’s head stuck on the top of the bed rails. RN 1 further stated the resident’s upper body was leaning against the bed rails with chest right side of the bed facing the window. RN 1 stated, “We needed to deflate the LAL mattress to be able to get her out.” During an interview and review of Resident 1’s medical record, on 5/16/21 at 10 am, RN 1 stated the resident’s Bedrail Use and Entrapment Risk Evaluation dated 3/24/2021 signed by RN 1 herself indicated bed dimensions had been checked and were appropriate for the resident’s size and weight. RN 1 stated that although the evaluation indicated the bed dimensions were appropriate, she was not aware of bed measurements or dimensions being measured. RN 1 stated she assumed the bed was appropriate for Resident 1’s size and weight and stated she did not get the dimensions based on Resident 1’s height and weight to mitigate the risk of entrapment for Resident 1between the bed rails and mattress. RN 1 stated it was important to assess the bed rail use and entrapment risk evaluation correctly for the resident’s safety and to avoid accidents such as residents being entrapped between bed rails and the mattress. 2a. A review of Resident 2’s Admission Record indicated the facility admitted a ninety-six year-old on 9/6/2011 with diagnoses of muscle weakness and difficulty walking. A review of Resident 2’s untitled care plan dated 6/22/2018, indicated Resident 2 required the use of two half padded side rails for bed mobility and nursing staff were to monitor safety during care and assess risk for entrapment. A review of Resident 2’s Order Summary Report dated 12/1/2020, indicated for the resident to have two padded bed rails (unidentified size) up when in bed for bed mobility. A review of Resident 2's MDS, dated 3/28/2021, indicated Resident 2 had severely impaired cognitive skills and required extensive assistance from staff for bed mobility and transfer. During an interview and a review of Resident 2’s medical record on 5/16/2021 at 10 am, RN 1 stated Resident 2’s Bedrail Use and Entrapment Risk Evaluation dated 6/24/2020 and signed by RN 1 herself, indicated Resident 2’s bed dimensions had been checked and were appropriate for Resident 2’s size and weight. RN 1 stated she assumed Resident 2’s bed was appropriate for the resident’s size and weight, but no measurements were done. During a concurrent observation of Resident 2 and interview with the DON on 5/14/2021 at 1:06 pm, Resident 2 was observed lying in bed, with bilateral half bed rails up with full length pads attached on both half bed rails. The DON stated, the pads should have been fitted to the bed rails and been secured in place. The DON added, it was important for the bed rail pads to fit the bed rails for resident’s safety and prevent entrapment. 2b. A review of Resident 3’s Admission Record indicated the facility admitted Resident 3, a seventy-eight-year-old on 1/5/2017 with diagnoses of epilepsy (brain disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), muscle weakness, left hemiplegia (paralysis of the left side of the body), and hemiparesis (weakness on one side of the body). A review of Resident 3’s untitled care plan dated on 5/22/2018, indicated Resident 3 required the use of two half padded bed rails (measurements not documented) for bed mobility and the nursing staff were to monitor safety during care, two padded bed rails while resident was in bed due to seizure precautions and risk for entrapment assessment. A review of Resident 3’s Order Summary Report dated 5/2/2020 indicated for Resident 3 to have two padded bed rails up (unidentified measurements) when in bed for seizure precautions. During a record review of Resident 3’s Bedrail Use and Ent