cms_AZ: 7
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2019-10-17 | 641 | D | 0 | 1 | EJUZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident and staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) assessment for one resident (#13) was accurate regarding restraints. The deficient practice could result in inaccuracies within the resident's clinical record. The census was 53 residents. Findings include: Resident #13 was admitted to the facility on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. A side rail usage assessment dated (MONTH) 15, 2019 revealed the resident required the assistance of one person to enter or exit the bed and was able to move and change positions in bed without assistance. The assessment included the resident preferred to have the rails in place and was able to enter and exit the bed on her own with the rails in use. A physician's orders [REDACTED]. Review of the care plan initiated (MONTH) 7, 2019 for quarter side rails as a therapeutic device to support mobility and independence revealed the goal was to enhance functional independence and promote skin integrity through the use of the right quarter rail for positioning and turning while in bed. Interventions included the resident uses the right side rail to assist with transfers. However, the quarterly MDS assessment dated (MONTH) 9, 2019 revealed resident #13 was coded as having bed rails used daily as a physical restraint. During an observation conducted of resident #13's room on (MONTH) 15, 2019 at 8:51 a.m., quarter rails was observed attached to each side of the resident's bed. An interview was conducted with resident #13 on (MONTH) 15 at 1:40 p.m. The resident stated she likes having the bed rails and that she uses them to help her get in and out of bed. She stated she does not use them all of the time, and the rails do not prevent her from getting out of bed. Resident #13 stated she is able to transfer from her wheelchair to the bed without assistance, and she is able to walk around her room without assistance. An interview was conducted with the MDS coordinator (staff #92) on (MONTH) 17, 2019 at 9:15 a.m. Staff #92 stated resident #13 uses the bed rails to assist her with getting in and out of bed. Staff #92 stated the resident has had the bed rails for a long time, and the resident feels safer with the bed rails up. Staff #92 stated she has checked the RAI manual guidelines and believes any use of bed rails qualifies as a restraint and must be coded as such on the MDS assessment. Staff #92 stated anyone in the facility with bed rails will have a restraint coded on their MDS assessment since the resident is not able to remove the bed rail in case of an emergency. She also stated the bed rail is not used as a restraint, but for mobility assistance. Another interview was conducted with the MDS coordinator (staff #92) on (MONTH) 17, 2019 at 10:45 a.m. Staff #92 stated that after checking with other staff, she has modified the resident's MDS assessment to remove the restraint. Staff #92 stated she was informed that since the bed rails do not restrict the resident's movement or ability to get in and out of bed, they are not classified as a restraint. An interview was conducted with the Director of Nursing (DON/staff #4) on (MONTH) 17 at 10:57 a.m. The DON stated the facility is restraint free and no resident should have a restraint coded on their MDS assessment. The DON stated that the bed rail does not restrict the resident's movement, and the resident is still able to get in and out of bed without assistance with the bed rails in place. Review of the RAI manual revealed physical restraints are 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 manual also revealed the assessors will evaluate whether or not a device meets the definition of a physical restraint and code only the devices that meet the definition; remember the decision about coding a restraint depends on the effect it has on the resident. The RAI manual included that it is required that the assessment accurately reflects the resident's status and that the importance of accuracy completing and submitting the MDS assessment cannot be overemphasized. | 2020-09-01 |