cms_WV: 11050
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11050 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2009-06-25 | 272 | E | 0 | 1 | OJEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the Long Term Care News Safety Alert January 2005 issued by the State survey and certification agency, review of the [MEDICATION NAME] low air loss mattress manufacturer's operating manual, and staff interview, the facility failed, for ten (10) of twenty-eight (28) sampled residents, to complete bed safety assessments for residents using a speciality mattress in conjunction with side rails, in order to identify and mitigate bed safety hazards. Resident identifiers: #4, #33, #43, #51, #66, #84, #103, #104, #114, and #129. Facility census: 128. Findings include: a) Observation Initial tour of the facility, on 06/22/09 at 2:30 p.m., revealed the facility had in use several speciality air beds. Further investigation revealed the [MEDICATION NAME] low air loss mattress systems in use were owned (not rented) by the facility. --- b) Safety Alert In January 2005, the State survey and certification agency issued to all WV Medicare / Medicaid certified nursing facilities and licensed nursing homes a Safety Alert regarding bed safety and entrapment hazards, which contained the following: "... It is highly recommended that all licensed nursing homes and/or Medicare / Medicaid certified nursing facilities immediately inspect all beds to identify areas of possible entrapment and take immediate action to reduce the risk of entrapment. "In 1995, the U.S. Food and Drug Administration (FDA) issued a Safety Alert entitled 'Entrapment Hazards with Hospital Bed Side Rails' to several groups of health care providers, including all nursing homes and hospital administrators. In this Alert, the FDA made the following recommendation: 'Inspect all hospital bed frames, bed side rails, and mattresses as part of a regular maintenance program to identify areas of possible entrapment. Regardless of the mattress width, length, and/or depth, alignment to the bed frame, bed side rail, and mattress should leave no gap wide enough to entrap a patient's head or body. Be aware that gaps can be created by movement or compression of the mattress which may be caused by patient weight, patient movement, or bed position...' "The Alert also reminded providers of their responsibility under the Safe Medical Devices Act of 1990, which requires hospitals and other user facilities to report deaths, serious illness, and injuries associated with the use of medical devices, including bed rails." -- The State survey and certification agency's 2005 Safety Alert also contained the following: "In April 2003, the Hospital Bed Safety Workgroup published Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings. "Suggested Bed Rail Safety Guidelines are as follows: " 'If it is determined that bed rails are required and that other environmental or treatment considerations may not meet the individual patient ' s assessed needs, or have been tried and were unsuccessful in meeting the patient ' s assessed needs, then close attention must be given to the design of the rail and the relationship between rails and other parts of the bed. 1. The bars within the bed rails should be closely spaced to prevent a patient ' s head from passing through the openings and becoming entrapped. 2. The mattress to bed rail interface should prevent an individual from falling between the mattress and bed rails and possibly smothering. 3. Care should be taken that the mattress does not shrink over time or after cleaning. Such shrinkage increases the potential space between the rails and the mattress. 4. Check for compression of the mattress's outside perimeter. Easily compressed perimeters can increase the gaps between the mattress and the bed rail. 5. Ensure that the mattress is appropriately sized for the selected bed frame, as not all beds and mattresses are interchangeable. 6. The space between the bed rails and the mattress and the headboard and the mattress should be filled either by an added firm inlay or a mattress that creates an interface with the beds rail that prevents an individual from falling between the mattress and bed rails. 7. Latches securing bed rails should be stable so that the bed rails will not fall when shaken. 8. Older bed rail designs that have tapered or winged ends are not appropriate for use with patients assessed to be at risk for entrapment. 9. Maintenance and monitoring of the bed, mattress, and accessories such as patient / caregiver assist items should be ongoing.' " --- c) In an interview, the director of nursing (DON - Employee #82) reported the [MEDICATION NAME] low air loss mattress manufacturer's operating manual identified that side rails must be used with this mattress. Employee #73 produced a copy of this operating manual to the survey team on 06/25/09. Review of the manual revealed: "[MEDICATION NAME] mattresses are not intended to be AND DO NOT FUNCTION AS a patient fall safety device. SIDE RAILS MUST BE USED WITH THE [MEDICATION NAME] MATTRESS TO HELP PREVENT FALLS, unless determined unnecessary based on the facility protocol or the patient's medical needs as determined by the facility, IN THESE CASES THE USE OF OTHER SUITABLE PATIENT SAFETY MEASURES ARE RECOMMENDED." The facility failed to complete individualized assessments for each resident using a [MEDICATION NAME] mattress to identify potential bed safety hazards and/or needs. . | 2014-09-01 |