Health inspection·May 19, 2021

§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)(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 72319. Nursing Service – Restraints and Postural Supports. (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. (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. The facility failed to prevent Certified Nursing Assistant (CNA 3) from using the bed sheet to tie Resident 1 to the wheelchair and applying a cloth gown around the resident’s waist then tied it at the back of the wheelchair. The facility also failed to prevent CNA 2 from wrapping a bed sheet around Resident 1's waist while in wheelchair. These failures had the potential to result in Resident 1 being strangulation or entrapment and increased agitation and aggression. A review of Resident 1's Face Sheet (Admission Record) indicated the facility initially admitted Resident 1, a 93 years-old-female, to the facility on 1/27/16 and readmitted on 2/13/20. Resident 1's diagnoses included schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), dementia (is a group of thinking and social symptoms that interfere with daily functions), and major depressive disorder (a mood disorder that causes a feeling of sadness and loss of interest in daily activities). A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 9/06/20, indicated Resident 1’s cognition (thought process) was severely impaired for daily decision-making. The MDS indicated Resident 1 required one-person limited physical assist (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) for bed mobility, transferring, walking in room and corridor, dressing, eating, toilet use and personal hygiene. A review of a facility document, titled "Interview Record: Allegation of Improper use of Resident Restraints" dated 7/29/20, indicated CNA 1 reported she had witnessed Resident 1 being restrained to a wheelchair. The document indicated CNA 1 stating that this incident had been going on since CNA 1 started at the facility over a year ago (5/20/2019). The document indicated "everyone" knows about it particularly Licensed Vocational Nurse (LVN) 1 and CNA 2. The document indicated CNA 1 had seen Resident 1 restrained when combative or agitated at the nursing station, hallway, and resident's room. A review of a facility document titled "Interview Record: Allegation of Improper use of Resident Restraints," dated 7/29/20, indicated CNA 2 was questioned by the facility administrator on whether she had "ever" restrained Resident 1 while in the wheelchair. The document indicated CNA 2 responded "yes she had," however, CNA 2 added that the resident had occasional behavior issues that increased her risk for fall and CNA 2 want to keep Resident 1 safe. The document indicated CNA 1 reported that LVN 1 and other CNAs were aware of this practice (restraining Resident 1). A review of a facility document titled "Interview Record: Allegation of Improper use of Resident Restraints," dated 7/29/20, indicated CNA 3's allegations to CNA 2 of restraining Resident 1 for a long time, "perhaps more than a year." The document indicated CNA 3 stating she believed that the restraints was done for Resident 1's safety since the resident had occasional behavioral outbursts that increased her risk of falling. A review of a facility document, titled "Interview Record: Allegation of Improper use of Resident Restraints," dated 7/29/20, indicated CNA 4 reported allegedly witnessing Resident 1 restrained to the wheelchair on three separate days, about a month ago (from the interview date), but did not witness who restrained Resident 1. A review of a facility document, titled "Interview Record: Allegation of Improper use of Resident Restraints," dated 7/29/20, indicated CNA 5 reported witnessing Resident 1 allegedly being restrained around the waist to the wheelchair, twice, approximately a month ago (from the interview date). A review of another document "Interview Record: Allegation of Improper use of Resident Restraints," dated 8/10/20 from CNA 3 indicated admitting that CNA 3 had also restrained Resident 1 previously, "but only to keep Resident 1 safe." A review of a facility document, titled "Complaint Regarding Professional Behavior of Colleagues," dated 8/10/20, indicated CNA 6 recalled that approximately a month ago (from the date of interview), CNA 6 had challenges with the care of Resident 1 and CNA 3 approached CNA 6 about restraining Resident 1 to the wheelchair to keep the resident safe. The document stated CNA 3 proceeded to tie the bedsheet around Resident 1. During an observation on 2/03/21 at 6:37 a.m., Resident 1 was observed in bed, awake and calm. During an attempt to interview, Resident 1 stared blankly and did not respond to questions. During an observation on 2/03/21 at 6:45 a.m., LVN 3 was observed entering the room of Resident 1. Resident 1 became attentive and communicated with LVN 3 in the Armenian language. During a subsequent interview of LVN 3, LVN 3 stated Resident 1 responds well when staff speak to her in Armenian. LVN 3 stated that Resident 1 understands English and most of the time would not answer when spoken in English. During an interview with Resident 1 on 2/03/21 at 6:50 am, LVN 3 translated in Armenian that Resident 1 did not respond directly to questioning regarding being tied up in the wheelchair. LVN 3 stated Resident 1 responded to basic questions of how her day had been. During an interview, on 2/03/21 at 7:27 a.m., the administrator stated he initially could not substantiate the allegation, until a previous employee spoke up. The administrator stated CNAs 1, 2, 3, 5, LVNs 1 and 2, night shift employees, were terminated or resigned from the facility due to the incident of Resident 1 being restrained (without physician’s order). During a concurrent interview and review of two photographs provided by the administrator, on 2/03/21 at 10:30 a.m., one photograph showed a resident (Resident 1), from a front view, sitting on a wheelchair with a white and blue cloth patient gown tied to the waist around the wheelchair. The administrator identified the resident, who was being tied to the wheelchair in the photograph, as Resident 1. In this photograph, Resident 1 had her arm extended reaching forward, with mouth wide opened. The second photograph showed the back of Resident 1 with the same white and blue patient gown tied in a knot at the resident’s waist level. The administrator stated he received these photographs from CNA 1 via text message on 7/29/20. During a telephone interview, on 2/09/21 at 12:14 p.m., CNA 5 stated she witnessed Resident 1 being tied to her wheelchair but did not know who tied Resident 1. CNA 5 stated CNA 3 was regularly assigned to provide care to Resident 1. CAN 5 stated CNA 3 would tie Resident 1 to her wheelchair by applying a cloth gown around the resident’s waist and tied it at the back of the wheelchair. CNA 5 stated she had seen Resident 1 being tied to her wheelchair since she started to work at the facility. During a telephone interview on 02/09/21 at 12:58 p.m., CNA 6 stated she did not work full time at the facility but recalled CNA 3 telling her to tie Resident 1 down (CNA 6 unable to recall date). CNA 6 stated she told CNA 3 that she could not do that. CNA 6 stated that CNA 3 explained to her it was for Resident 1's safety since Resident 1 would get agitated. CNA 6 stated she did not report what CNA 3 told her because she had not actually seen Resident 1 being tied up, so she did not know if it was something CNA 3 had been doing before. On 2/22/21 at 1:05 p.m., during a review of Resident 1's records with the director of nursing (DON), the DON verified that there was no physician's order for the staff to apply the physical restraint to Resident 1. The DON stated there were no care plans that indicated interventions implemented for Resident 1's behavior during night shift to prevent staff from restraining Resident 1. A review of Resident 1's care plan dated 11/13/19 and reevaluated dated 5/2020, indicated the resident randomly screams without purpose which affects other residents. The care plan interventions indicated Resident 1 would be monitored closely by staff members and had a caregiver during the day to monitor the resident one-on-one. A review of Resident 1's care plan, titled "Behavior" dated 2/1/20 and reevaluated dated 5/1/2020, indicated Resident 1 had episodes of going out to the patio unassisted. The care plan indicated Resident 1 had episodes of being aggressive when staff would try to assist, high risk for fall and injury, and elopement (to escape or run away). The care plan interventions included assessing what may cause Resident 1's behavior and what may trigger behavior and attempt to reduce/eliminate those triggers if possible. The interventions indicated to respect Resident 1's rights to refuse treatment and care. During a telephone interview on 2/22/20 at 1:05 p.m., the DON stated the use of physical restraint was not a facility practice. The DON stated that restraining Resident 1 physically was a form of abuse. The DON stated nurses should always assess the residents for behavior and should try to figure out the cause of the behavior if it was associated to pain. The DON stated the nurses should try to figure out if the resident needed one-to-one monitoring and should not restrain the resident. During a concurrent review of Resident 1's care plans titled Behavior, the DON stated Resident 1 used to have a one-on-one caregiver (Caregiver 1) during the day provided and hired by Resident 1's family. The DON stated Caregiver 1 would come during the day and stay with Resident 1. The DON stated it had been a while that Caregiver 1 was in the facility to stay with Resident 1 (since November 2019). The DON could not provide documented evidence from Resident 1's medical records of nursing interventions provided by the licensed nurses and CNAs to manage Resident 1's behavior during the night shift. During a telephone interview, on 3/23/21 at 2:20 p.m., the administrator stated that Caregiver 1 was a companion for Resident 1 during daytime unlike what the care plan indicated. The administrator stated Resident 1 would have occasional outburst behavior and that was when CNAs would stay with her during the day. The administrator stated the CNAs would "sit in" with Resident 1 for a few hours. The administrator stated Resident 1 did not require constant one-on-one care. A review of the facility's policy and procedure titled, "Use of Restraints," revised on September 2013 indicated restraints shall only be used to treat the resident's medical symptoms(s) and never for discipline or staff convenience, or for the prevention of falls. The facility failed to ensure 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. 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, including but not limited to: The facility failed to prevent Certified Nursing Assistant (CNA 3) from using the bed sheet to tie Resident 1 to the wheelchair and applying a cloth gown around the resident’s waist then tied it at the back of the wheelchair. The facility also failed to prevent CNA 2 from wrapping a bed sheet around Resident 1's waist while in wheelchair. These failures had the potential to result in Resident 1 being strangulation or entrapment and increased agitation and aggression. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.