| 35 |
LEFA SERAN SNF |
295001 |
1ST AND A ST/ PO BOX 1510 |
HAWTHORNE |
NV |
89415 |
2018-02-16 |
700 |
E |
1 |
0 |
T81R11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, clinical record review, and document review, the facility failed to ensure the residents were offered alternatives prior to the use of bed rails, evaluated for safety to include entrapment, informed on the reason the resident required the use of side rails, monitored usage, and implemented a reduction of use for 20 of 24 sampled residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #13, #16, #17, #18, #20, #21, #22, #23, #24). Findings include: Resident #18 Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/16/18 at 9:36 AM, Resident #18 was in bed with a half side rails up on each side of the bed. Resident #18's physicians order, dated 04/17/14, documented the resident may use side rails for bed mobility. Resident #18's care plans lacked documented evidence of side rails. A care plan for high risk for falls, last revised on 05/05/14, indicated slide fails were to be used as ordered. Resident #18's clinical record lacked documented evidence of an assessment for entrapment, monitoring for usage, informed consent for the risks and benefits, assessments for the need for ongoing usage, a plan for reduction of use, interventions implemented prior to usage, and a care plan specific to side rail usage. Resident #13 Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 02/16/18 at 9:38 AM, Resident #13's bed had quarter side rails up on each side of the bed. Resident #13's care plan, revised on 09/13/17, documented the resident had impaired physical mobility , impaired coordination, inability to move independently in bed and required half rails to turn and reposition. The intervention/tasks indicated the resident will be independent with half rails. Resident #13's clinical record lacked documented evidence of an assessment for entrapment, monitoring for usage, informed consent for the risks and benefits, assessments for the need for ongoing usage, a plan for reduction of use, interventions implemented prior to usage, and a care plan specific to side rail usage. Resident #10 Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/16/18 at 9:40 AM, Resident #10 was asleep in bed with a half side rail up on the right side of the bed. Resident #10's physicians order, dated 07/09/13, documented the resident may use side rails for bed mobility. Resident #10's care plan documented the resident had impaired physical mobility, fatigue and lethargy and inability to move independently and required half side rails to aide her in turning and repositioning in bed. The goal had been for resident to move about in bed with or without assistance of half rails on the bed, to aide her in bed mobility. The intervention/task indicated the resident will be independent with bed mobility enabled by half rails on the bed. Resident #10's clinical record lacked documented evidence of an assessment for entrapment, monitoring for usage, informed consent for the risks and benefits, assessments for the need for ongoing usage, a plan for reduction of use, and interventions implemented prior to usage. Resident #21 Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 02/16/18 at 9:43 AM, Resident #21 was not in the room, the bed had left half side rails up. Resident #21's physician's orders [REDACTED]. Resident #21's care plan, last revised on 09/13/17, documented the resident had impaired physical mobility, impaired coordination, inability to move independently and required half side rails to reposition and turn in bed. The intervention/task indicated the resident would be independent with half rails in bed. Resident #21's clinical record lacked documented evidence of an assessment for entrapment, monitoring for usage, informed consent for the risks and benefits, assessments for the need for ongoing usage, a plan for reduction of use, interventions implemented prior to usage. Resident #9 Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 02/16/18 at 9:44 AM, Resident #9 was in bed with a half side rails up on the right side of the bed. Resident #9's physicians order, dated 03/21/14 documented the resident may use the side rails for bed mobility. Resident #9's care plans lacked documented evidence of side rails. Resident #9's clinical record lacked documented evidence of an assessment for entrapment, monitoring for usage, informed consent for the risks and benefits, assessments for the need for ongoing usage, a plan for reduction of use, interventions implemented prior to usage, and a care plan specific to side rail usage Resident #24 Resident #24 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 02/16/18 at 9:50 AM, Resident #24 was asleep in bed, with a quarter side rail up on right side. Resident #24's physician's orders [REDACTED]. Resident #24's care plan, dated 10/05/17, documented the resident had poor bed mobility related to cognitive deficit but used half rails to turn and reposition herself in bed. The intervention indicated half rails will remain up while the resident was in bed for bed mobility. Resident #24's clinical record lacked documented evidence of an assessment for entrapment, monitoring for usage, informed consent for the risks and benefits, assessments for the need for ongoing usage, a plan for reduction of use, and interventions implemented prior to usage. Resident #7 Resident #7 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 02/16/18 at 9:51 AM, Resident #7's bed had half side rails up on each side of the bed. Resident #7's physician order, dated 02/01/12, documented the resident may use side rails for bed mobility. Resident's #7's care plan, last revised 09/13/17, documented the resident had impaired physical mobility, impaired coordination and inability to move independently in bed and required half rails to turn and reposition self independently. The goal and intervention/tasks were for resident to move about in bed with minimum physical assistance. Resident #7's clinical record lacked documented evidence of an assessment for entrapment, monitoring for usage, informed consent for the risks and benefits, assessments for the need for ongoing usage, a plan for reduction of use, interventions implemented prior to usage. Resident #16 Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 02/16/18 at 9:53 AM, Resident #16 was awake in bed with half side rails up on both sides. Resident #16's physician's orders [REDACTED]. Resident #16's care plan, last revised on 09/13/17, documented the resident had impaired physical mobility, decreased balance, impaired coordination, inability to move independently in bed required bed half rails to enable her to turn and reposition herself. Resident #16's clinical record lacked documented evidence of an assessment for entrapment, monitoring for usage, informed consent for the risks and benefits, assessments for the need for ongoing usage, a plan for reduction of use, interventions implemented prior to usage. Resident #20 Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 02/16/18 at 9:56 AM, Resident #20 was awake in bed in the upright position with quarter side rails up on each side of the bed. Resident #20's physician's orders [REDACTED]. Resident #20's care plan, last revised on 01/30/18, documented the resident had impaired physical mobility impaired coordination, inability to move independently and to enable her to turn and reposition herself and required half rails on the resident's bed. Resident #20's clinical record lacked documented evidence of an assessment for entrapment, monitoring for usage, informed consent for the risks and benefits, assessments for the need for ongoing usage, a plan for reduction of use, interventions implemented prior to usage. Resident #8 Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/16/18 at 9:57 AM, Resident #8's bed had quarter side rails up on each side. Resident #8's physician order, dated 11/28/17, documented the resident may use side rails for bed mobility. Resident #8's care plans lacked documented evidence of side rails. Resident #8's clinical record lacked documented evidence of an assessment for entrapment, monitoring for usage, informed consent for the risks and benefits, assessments for the need for ongoing usage, a plan for reduction of use, interventions implemented prior to usage, and a care plan specific to side rail usage. Resident #23 Resident #23 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 02/16/18 at 9:58 AM, Resident #23 was in bed, sleeping, with a half side rails up on each side of the bed. Resident #23's physician's orders [REDACTED]. Resident #23's care plan, last revised on 11/16/17, documented the resident had impaired transfer ability physical limitations secondary to left sided weakness. The resident's care plans lacked documented evidence of side rail usage. Resident #23's clinical record lacked documented evidence of an assessment for entrapment, monitoring for usage, informed consent for the risks and benefits, assessments for the need for ongoing usage, a plan for reduction of use, interventions implemented prior to usage, and a care plan specific to side rail usage. Resident #5 Resident #5, was admitted on [DATE] with [DIAGNOSES REDACTED]. On 02/16/18 at 9:59 AM, Resident #5 was in bed with a half side rails up on each side of the bed. Resident #5's physician order, dated 10/18/16, documented the resident may use side rails for bed mobility. Resident #5's care plan, last revised on 10/17/17, documented the resident had impaired bed mobility, inability to move independently in bed and required bed half rails to turn and reposition himself. The intervention/task had been for the resident to be independent with use of bed half rails. Resident #5's clinical record lacked documented evidence of an assessment for entrapment, monitoring for usage, informed consent for the risks and benefits, assessments for the need for ongoing usage, a plan for reduction of use, interventions implemented prior to usage. Resident #22 Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 02/16/18 at 10:01 AM, Resident #22's bed had a quarter side rails up on each side. Resident #22's physician's orders [REDACTED]. Resident #22's care plan, last revised on 03/17/12, documented the resident had an Assistance of Daily Living (ADL) self-care performance deficit related to dementia, limited mobility. The intervention/task indicated side rails may be used per physician's orders [REDACTED]. Observe for injury or entrapment related to side rails. Reposition as needed to avoid injury. Resident #22's clinical record lacked documented evidence of an assessment for entrapment, monitoring for usage, informed consent for the risks and benefits, assessments for the need for ongoing usage, a plan for reduction of use, interventions implemented prior to usage. Resident #17 Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/16/18 at 10:06 AM, Resident #17 was in her room in wheelchair. Her bed had the sheets off. The egg crate was exposed and a quarter side rail up on the left and a half side rail up on the right side of the bed. Resident #17's physician's orders [REDACTED]. Resident #17's care plan, last revised on 09/13/17, documented the resident had impaired physical mobility, decreased balance, impaired coordination, inability to move independently and required bed half rails to turn and reposition herself in bed. Resident #17's clinical record lacked documented evidence of an assessment for entrapment, monitoring for usage, informed consent for the risks and benefits, assessments for the need for ongoing usage, a plan for reduction of use, interventions implemented prior to usage. Resident #4 Resident #4, was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 02/16/18 at 10:12 AM, Resident #4 was in bed, with half side rails up on each side of the bed. Resident #4's physician order, dated 10/24/14, documented the resident may use side rails. Resident #4's care plan, last revised on 09/18/17, documented the resident had an ADL self-care performance deficit related to dementia, limited mobility, and used the quarter bed rails to turn on her side while in bed. The tasks/interventions were to keep bed in lowest position and keep quarter side rails up while the resident was in bed, except when rendering care. Resident #4's clinical record lacked documented evidence of an assessment for entrapment, monitoring for usage, informed consent for the risks and benefits, assessments for the need for ongoing usage, a plan for reduction of use, interventions implemented prior to usage. Resident #6 Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 02/16/18 at 10:14 AM, Resident #6 was awake in upright position in bed, with a left half side rails up and a right quarter side rail up. Resident #6's physician order, dated 7/13/17, documented the resident may use side rails for bed mobility. Resident #6's care plan documented the resident required half rails in bed for assistance to turn and reposition herself. The intervention/task indicated the resident would be able to turn and reposition herself with use of half rails after verbal cues. Resident #6's clinical record lacked documented evidence of an assessment for entrapment, monitoring for usage, informed consent for the risks and benefits, assessments for the need for ongoing usage, a plan for reduction of use, interventions implemented prior to usage. Resident #11 Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 02/16/18 at 10:18 AM, Resident #11 was asleep, in bed with no side rails up. Resident's bed had half side rails attached on each side of the bed. Resident #11's physician's orders [REDACTED]. Resident #11's care plans lacked documented evidence of bed rail usage. Resident #11's nursing progress notes lacked documentation of usage or non-usage of side rails. Resident #11's clinical record lacked documented evidence of an assessment for entrapment, monitoring for usage, informed consent for the risks and benefits, assessments for the need for ongoing usage, a plan for reduction of use, interventions implemented prior to usage, and a care plan specific to side rail usage. Resident #1 Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 02/16/18 at 10:20 AM, Resident #1's bed had a half side rails up on each side of the bed. Resident #1's physician order, dated 12/19/17, documented the resident may use side rails for bed mobility. Resident #1's care plans lacked documented evidence of side rails. Resident #1's clinical record lacked documented evidence of an assessment for entrapment, monitoring for usage, informed consent for the risks and benefits, assessments for the need for ongoing usage, a plan for reduction of use, interventions implemented prior to usage, and a care plan specific to side rail usage. Resident #3 Resident #3, was admitted on [DATE] with [DIAGNOSES REDACTED]. On 02/16/18 at 10:21 AM, Resident #3's bed had half side rails lowered on each side. Resident #3's physician order, dated 03/28/17, documented the resident may use side rails for bed mobility. Resident #3's care plans lacked documented evidence of side rails. Resident #3's clinical record lacked documented evidence of an assessment for entrapment, monitoring for usage, informed consent for the risks and benefits, assessments for the need for ongoing usage, a plan for reduction of use, interventions implemented prior to usage, and a care plan specific to side rail usage. Resident #2 Resident #2, was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 02/16/18 at 10:22 AM, Resident #2 was in bed, with a three-quarter side rails up on each side of the bed. Resident #2's physician order, dated 01/17/12, documented the resident may use side rails. Resident #2's care plans lacked documented evidence of side rails. Resident #2's clinical record lacked documented evidence of an assessment for entrapment, monitoring for usage, informed consent for the risks and benefits, assessments for the need for ongoing usage, a plan for reduction of use, interventions implemented prior to usage, and a care plan specific to side rail usage. On 02/16/18 at 2:29 PM, the Director of Nursing (DON) explained the residents had bed rails to help them turn or assist them in getting up. The DON verbalized if residents could not understand the reason for side rail usage then they could not have side rails on their bed. The DON confirmed the facility did not have an assessment for entrapment done prior to side rail installation and did not complete quarterly assessment for usage of side rails. The DON confirmed the facility had standing orders for side rails, the physician did not evaluate the residents prior to writing the order and a care plan would be required. The DON confirmed the facility did not obtain informed consents for risks and benefits of side rails, document the monitoring for the usage of bed rails, or provide and attempt alternatives prior to the usage of side rails. |
2020-09-01 |