cms_ID: 5
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5 | ST LUKE'S ELMORE LONG TERM CARE | 135006 | 895 NORTH 6TH EAST | MOUNTAIN HOME | ID | 83647 | 2020-01-24 | 641 | E | 0 | 1 | JSJS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and resident and staff interview, the facility failed to ensure MDS assessments accurately reflected the resident's status. This was true for 5 of 8 residents (#1, #5, #8, #11, and #12) whose MDS assessments were reviewed for accuracy. This failure created the potential for harm should residents receive inappropriate care related to discrepancies in the MDS assessment. Findings include: The facility's Restraint Policy, revised on 9/20/19, stated, Physical Restraint/Hold: Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his arms, legs, body or head freely and/or a measure to prevent patient from exiting the bed/chair (e.g., mitts tied down, soft or leather wrist or ankle straps. The CMS Resident Assessment Instrument (RAI) Manual, Version 3.0, dated (MONTH) 2019, which is used as an instruction manual for completing MDS assessments, defines physical restraints 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 use of bed rails in the facility did not meet the definition of a physical restraint as documented in residents' MDS assessments, as follows: a. Resident #1 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #1's MDS assessments, dated 11/26/18, 2/19/19, 5/17/19, 8/17/19, and 11/15/19, documented bed rails were used daily as physical restraints. Resident #1's bed rail assessments, dated 2/19/19, 5/17/19, 8/16/19 and 11/15/19, documented bed rails were medically necessary and used for bed mobility, entering and exiting the bed safely, turning side to side, and positioning and moving up and down. The assessments did not include documentation the bed rails were used as a restraint. On 1/22/20 at 5:00 PM, Resident #1 was observed laying in her bed with the left side against the wall and the bed rails were up. Resident #1 stated she used the bed rails to help her get in and out of bed. b. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Risks and Benefits of Side Rails consent for use of bed rails for Resident #5 was signed by a family member on 4/2/19. Resident #5's MDS assessments, dated 4/9/19, 10/2/19, and 1/2/20, documented bed rails were used daily as a physical restraint. The initial bed rail assessment, dated 5/22/19, documented bed rails were medically necessary to assist Resident #5 for bed mobility, moving up and down in bed, and for transfer exiting and entering the bed more safely. The assessment documented the bed rails would not impede Resident #5's freedom of movement. The assessment did not include documentation the bed rails were used as a restraint. Resident #5's quarterly bed rail assessments dated 7/9/19, 10/2/19, and 1/2/20, documented the bed rails were used for supporting herself, improving balance, transferring more safely, turning side to side, and pulling herself from a laying to a sitting position. The assessments documented the bed rails would not impede Resident #5's freedom of movement. The assessments did not include documentation the bed rails were used as a restraint. During an interview with Resident #5 on 1/22/20 at 3:15 PM, she stated she used the bed rails when she was in bed, so she could reposition herself and the bed rails did not prevent her from getting out of the bed. c. Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Risks and Benefits of Side Rails consent for use of bed rails was signed by Resident #8 on 12/3/18. Resident #8's MDS assessments, dated 12/10/18, 3/4/19, 6/4/19, 9/4/19, and 12/3/19, documented bed rails were used daily as a physical restraint. Resident #8's initial bed rail assessment, dated 12/3/18, and the subsequent quarterly assessments dated 3/4/19, 6/4/19, 9/6/19, and 12/3/19, documented the bed rails were recommended due to Resident #8's bladder incontinence, assistance of one person for toileting, diuretic use, and orthostatic medication use. The assessments documented the bed rails would not impede Resident #8's freedom of movement and the right upper bed rail had the bed controls imbedded in the rail. The assessments did not include documentation the bed rails were used as a restraint. During an interview with Resident #8 on 1/23/20 at 9:38 AM, she stated she had one bed rail on her bed that was used because it had the bed controls on the rail. She stated the rail did not keep her from getting out of bed. d. Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Risks and Benefits of Side Rails consent for use of bed rails was signed by Resident #11 on 5/21/19. Resident #11's MDS assessments, dated 5/21/19, 8/21/19, and 11/21/19, documented bed rails were used daily as a physical restraint. Resident #11's initial bed rail assessment, dated 5/21/19, and the subsequent quarterly assessments for bed rails, dated 8/21/19, and 11/21/19, documented the bed rails were medically necessary to assist Resident #11 with bed mobility, for turning side to side, moving up and down in bed, pulling herself from a laying to a sitting position, and for transfer for improving balance and supporting herself. The assessments documented bed rails would not impede Resident #11's freedom of movement. The assessments did not include documentation the bed rails were used as a restraint. During an interview with Resident #11 on 1/23/20 at 3:15 PM, she stated she used the bed rails when she was in bed, so she could reposition herself and the bed rails did not prevent her from getting out of the bed. e. Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #12's MDS assessments, dated 11/17/18, 2/7/19, 5/7/19, 8/7/19, and 11/7/19, documented bed rails were used daily as a physical restraint. A Risks and Benefits of Side Rails consent for use of bed rails for Resident #12 was signed by a family member on 6/15/17. Resident #12's bed rail assessments, dated 2/7/19. 5/7/19, 8/6/19, and 11/7/19, documented the bed rails were medically necessary to assist Resident #12 with bed mobility, turning side to side, and pulling herself from a laying to sitting position. The bed rail was recommended due to conditions of dementia, bladder incontinence, assistance of two people for toileting, and orthostatic medications (blood pressure medications). The assessments stated the bed rails would not impede Resident #12's freedom of movement. The assessments did not include documentation the bed rails were used as a restraint. During an interview with Resident #12 on 1/21/20 at 9:45 AM, she stated she had one bed rail on her bed and used it to help pull herself up in bed. Resident #12 was observed on 1/22/20 at 9:48 AM, in bed with the upper bed rail on the right side of the bed in the raised position, with a pillow propped against it. Resident #12 stated it did not keep her from getting out of bed and she could not get out of bed without assistance from staff. On 1/22/20 at 9:02 AM, the MDS Coordinator stated bed rails are not used to restrict the residents but allowed them bed mobility. She stated the bed rails were coded as restraints because the residents could not lower the bed rails by themselves. She stated the bed rails in use did not prevent any of the residents using them from getting out of bed or restrict their movement. On 1/23/19 at 2:00 PM, the Administrator brought forward the CMS RAI Manual, dated (MONTH) 2019, the reference used for coding bed rails as a positioning device. She referenced Section P: Physical Restraints, Bed rails used as positioning devices: If the use of bed rails (quarter-, half- or three-quarter, one or both, etc.) meet the definition of a physical restraint even though they may improve the resident's mobility in bed, the nursing home must code their use as a restraint at P0100[NAME] The surveyor explained to the Administrator the bed rails as used by the residents did not meet the definition of a physical restraint. | 2020-09-01 |