| 3 |
PERSHING GENERAL HOSPITAL SNF |
295000 |
855 6TH STREET |
LOVELOCK |
NV |
89419 |
2019-02-06 |
700 |
E |
0 |
1 |
GLV211 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, interview, and document review, the facility failed to assess for the risk of entrapment for the use of side rails for 10 of 12 sampled residents (Resident #2, #3, #4, #6, #9, #16, #18, #19, #20, and #23), and attempt to use appropriate alternatives prior to installation of side rails for 12 of 12 sampled residents (Resident #2, #3, #4, #6, #7, #9, #10, #16, #18, #19, #20, and #23). Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. On 02/05/19 at 4:10 PM, Resident #2's bed had two, one-quarter (1/4) sized side rails attached to either side of the bed. Both side rails were in the up position. Resident #2's clinical record lacked documented evidence an assessment for the risk of entrapment and appropriate alternatives were attempted prior to the installation and use of side rails. Resident #3 Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 02/05/19 at 4:09 PM, Resident #3's bed had four, one-quarter (1/4) sized side rails attached to either side of the bed. Three of the four side rails were in the up position. Resident #3's clinical record lacked documented evidence an assessment for the risk of entrapment and appropriate alternatives were attempted prior to the installation and use of side rails. Resident #4 Resident #4 was admitted to the facility on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. On 02/05/19 at 4:08 PM, Resident #4's bed had two, one-quarter (1/4) sized side rails attached to either side of the bed. Both side rails were in the up position. Resident #4's clinical record lacked documented evidence an assessment for the risk of entrapment and appropriate alternatives were attempted prior to the installation and use of side rails. Resident #6 Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 02/05/19 at 4:12 PM, Resident #6's bed had two, one-quarter (1/4) sized side rails attached to either side of the bed. Both side rails were in the up position. Resident #6's clinical record lacked documented evidence an assessment for the risk of entrapment and appropriate alternatives were attempted prior to the installation and use of side rails. Resident #7 Resident #7 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. On 02/04/19 at 10:18 AM, Resident #7's bed had two, one-quarter (1/4) sized side rails attached to either side of the bed. Both side rails were in the up position. Resident #7's clinical record lacked documented evidence appropriate alternatives were attempted prior to the installation and use of side rails. Resident #9 Resident #9 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. On 02/04/19 at 10:12 AM, Resident #9's bed had two, one-quarter (1/4) sized side rails attached to either side of the bed. Both side rails were in the up position. Resident #9's clinical record lacked documented evidence an assessment for the risk of entrapment and appropriate alternatives were attempted prior to the installation and use of side rails. Resident #10 Resident #10 was admitted to the facility on [DATE], and re-admitted on [DATE], with a [DIAGNOSES REDACTED]. On 02/05/19 at 4:13 PM, Resident #10's bed had four, one-quarter (1/4) sized side rails attached to either side of the bed. Two of the four side rails were in the up position. Resident #10's clinical record lacked documented evidence appropriate alternatives were attempted prior to the installation and use of side rails. Resident #16 Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 02/05/19 at 4:10 PM, Resident #16's bed had two, one-quarter (1/4) sized side rails attached to either side of the bed. Both side rails were in the up position. Resident #16's clinical record lacked documented evidence an assessment for the risk of entrapment and appropriate alternatives were attempted prior to the installation and use of side rails. Resident #18 Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 02/04/19 at 10:12 AM, Resident #18's bed had two, one-quarter (1/4) sized side rails attached to either side of the bed. Both side rails were in the up position. Resident #18's clinical record lacked documented evidence an assessment for the risk of entrapment and appropriate alternatives were attempted prior to the installation and use of side rails. Resident #19 Resident #19 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. On 02/05/19 at 4:07 PM, Resident #19's bed had two, one-quarter (1/4) sized side rails attached to either side of the bed. Both side rails were in the down position. Resident #19's clinical record lacked documented evidence an assessment for the risk of entrapment and appropriate alternatives were attempted prior to the installation and use of side rails. Resident #20 Resident #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 02/05/19 at 4:11 PM, Resident #20's bed had two, one-quarter (1/4) sized side rails attached to either side of the bed. Both side rails were in the up position. Resident #20's clinical record lacked documented evidence an assessment for the risk of entrapment and appropriate alternatives were attempted prior to the installation and use of side rails. Resident #23 Resident #23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 02/05/19 at 4:14 PM, Resident #23's bed had two, one-quarter (1/4) sized side rails attached to either side of the bed. Both side rails were in the up position. Resident #23's clinical record lacked documented evidence an assessment for the risk of entrapment and appropriate alternatives were attempted prior to the installation and use of side rails. On 02/06/19 at 9:20 AM, the Chief Nursing Officer (CNO) confirmed Residents #7 and #10's clinical record lacked documented evidence appropriate alternatives were attempted prior to the installation and use of side rails. The CNO confirmed Resident #2, #3, #4, #6, #7, #9, #10, #16, #18, #19, #20, and #23's clinical record lacked documented evidence assessment for the risk of entrapment and appropriate alternatives were attempted prior to the installation and use of side rails. The CNO confirmed appropriate use of alternatives and assessments for the risk of entrapment should have been completed prior to the installation of side rails. An undated facility policy titled, Bed and Side Rails, Long Term Care, documented residents were to have been assessed for the risk of entrapment for the use of side rails. The policy lacked documentation of the requirement for the attempted use of appropriate alternatives prior to the installation of side rails. |
2020-09-01 |