cms_PR: 578
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 578 | SAN GERARDO HOSP | 405022 | MSC 250 WINSTON CHURCHIL AVE 138 | RIO PIEDRAS | PR | 926 | 2013-09-13 | 221 | K | F6TZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure that each resident was free from physical restraints, unless needed to treat a medical symptom. Seven residents (R1, R2, R3, R8, R10, R16, and R17) of 17 in the standard and extended sample, were restrained to their beds through the use of limb restraints, which kept them tied to the bed. Fourteen (R1, R2, R3, R4, R5, R7, R8, R9, R10, R11, R12, R13, R16, and R17) of 15 current residents in the standard and extended sample were restrained in bed through the use of four side rails (one top and one bottom rail on each side of the bed). Residents were restrained for staff convenience (i.e. to provide supervision, to assure that residents did not get out of bed, and to relieve staff fears that residents would fall). Residents were restrained without consent. Restraints were used prior to an interdisciplinary assessment to evaluate resident behaviors. Less restrictive measures were not attempted prior to restraint use. Restraints were applied without physician orders. Care plans were not developed for the removal/reduction of restraints. At least three residents (R3, R16, and R17) sustained falls while restrained which required physician intervention. An additional resident (R8) was found wedged between the side rails, hanging from the wrist restraints during the standard and extended survey. The facility failed to conduct an assessment of the potential risks that these restraints created, even when they were aware that multiple residents had sustained accidents. The failure to assure that residents were free from physical restraints was identified as Immediate Jeopardy on 9/11/13, and was found to affect 42 of 64 residents in the facility. The facility did not allege abatement of the Immediate Jeopardy prior to surveyor exit from the facility on 9/13/13. Findings: 1. Observation during initial tour on 9/9/12 at 12:20 revealed R3 lying in bed. The resident had sutures over his right eyebrow, with faint bruising around the area. R3 was restrained in bed, with four quarter side rails up (one top and bottom rail on each side of the bed). In addition, both of the resident's arms were restrained with soft wrist restraints. R3's right wrist restraint was tied to the upper right side rail, while the left wrist restraint was tied to the bed frame under the left side rail. Interview with the Director of Nursing (DON) during the tour revealed R3 had sustained two falls from the bed while restrained with side rails. The DON related that the resident had been found on the floor, and sustained a wound on the forehead as a result. Further observation on 9/9/13 at 1:50pm, 2:30pm, 3:00pm and 3:45pm; 9/10/13 at 8:00am, 8:20am, 9:05am, 10:00am, 11:10am, 12:30pm, and 2:00pm; 9/11/13 at 9:00am, 10:05am, 10:45am, 12:02pm, 12:20pm, 2:28pm, 3:35pm, and 4:25pm; 9/12/13 at 8:20am, 8:55am, 10:30am, 11:15am, 1:45pm, and 3:00pm; and 9/13/13 at 8:25am, and 9:00am, also revealed R3 was restrained with 4 side rails up and wrist restraints Review of the clinical record revealed the R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, completed on 9/4/13, revealed the resident was alert, oriented to person, cooperative, and could usually understand what others were saying. The resident was identified as continent of urine, and needed assistance with toileting. Review of the form titled, "Consentimiento Informado" (Informed Consent) revealed on 9/4/13, the family had given permission for the facility to use "barandas elevadas" (raised side rails) for "prevencion de caidas" (prevention of falls). Further review of the clinical record lacked documented evidence the family had given permission for the use of wrist restraints, or been educated as to their associated risks. Review of physician orders revealed from the date of admission (9/4/13), there were orders to restrain both the resident's wrists (There were no orders for the use of the full, bilateral side rails, which also restrained the resident). Although the admission assessment indicated the resident was cooperative, and no behaviors were noted, the 9/4/13 order stated the resident was demonstrating "agitacion" (agitation) and "desorientacion" (disorientation). The section of the medical order on which the doctor was to document "razon para restringer" (reason for restraint) was blank. The pre-printed physician's order included a section in which the physician was to identify factors influencing the resident's conduct; however, this section was also blank. The pre-printed physician's order form also included a section for the doctor to document options which had been considered prior to restraint use. This section of the form was also incomplete. Further review of the clinical record lacked documented evidence of interdisciplinary assessment as to the need for a restraint (either the side rail or the wrist restraint) prior to the initial application. The clinical record also lacked documented evidence that any less restrictive measures had been attempted, prior to the resident being restrained. Review of R3's clinical record also revealed no initial care plan for the problem of restraint use had been developed, nor was there a plan for the reduction/removal of restraints. Review of the form for physician's order for restraints revealed the order could not exceed 24 hours. However, review of the clinical record on 9/10/13 revealed that the last order for restraints (wrist restraints only - no order for full side rails) had been written on 9/5/13. Review of this order revealed that the physician had documented the resident was "incapable of following instructions" as the conduct R3 had shown which required the use of a restraint; again, the MD failed to document any factors influencing the resident's conduct, or options considered prior to restraining the resident in bed. Although (as of 9/10/13) there were no further orders for restraint use after 9/5/13, review of the daily nursing notes for 9/6 - 9/10/13 revealed that each day the resident had "restricciones" (the wrist restraints) as well as raised upper and lower side rails. Further review of the clinical record revealed on two of the days for which there were no restraint orders (9/7/13 and 9/8/13), R3 was found on the floor and required computer tomography (CT) scans, due to the potential for head injury. In addition, as a result of the 9/7/13 fall while restrained, R3 required sutures to the area above the right eyebrow. (Refer to F323). On 9/11/13, further review of the clinical record revealed R3's record now contained orders for wrist restraints for 9/6 - 9/10/13. Review of these orders, which were all originally dated 9/10/13 then altered to show different dates, revealed that they were written by a medical student and not by the resident's licensed physician. Interview with a family member (F3) of R3 on 9/9/13 at 3:45pm revealed her concern that the resident had declined in less than one week of admission. F3 stated that when R3 was admitted to the facility he was alert, talking, knew where he was and that he was going to receive rehabilitation. However, since his admission he had been restrained and fallen twice (Refer to F323). F3 related that the family had signed a consent form for restraints because the facility "have not talked to us about any other options" to prevent falls. She stated the reason her father was trying to get out of bed was because he was hungry (Refer to F325) and wet from lying in urine. Further interview with F3 revealed facility staff "are keeping him tied down to keep him in bed" because the family "can't be here all night." F3 added that "We understood they (the facility) couldn't supervise him at night." When told that the facility was responsible for supervision of the resident at all times, F3 had tears in her eyes as she stated, "That's what we thought." Interview with Licensed Practical Nurse (LPN) 36 on 9/10/13 at 8:15am revealed he provided care for R3, and was aware of his status. Further interview with LPN36 revealed the resident had full side rails and his arms tied to the bed because of staff fears that the resident would fall if he were not restrained. LPN36 also stated R3 was disoriented and staff was afraid he would try to get out of bed if he were not tied down. Interview with the DON on 9/10/13 at 8:30am revealed the facility did not assess residents prior to the use of restraints. The DON stated the facility had no evidence that less restrictive measures were attempted prior to restraint use, as the only thing needed to restrain a resident was a physician's order. Further interview with the DON on 9/11/13 at 9:00am revealed that even after two falls from the bed while restrained, the facility had not considered the need to remove R3's restraints and attempt other interventions. She stated that since the family told her they could not be at the facility all the time, "we have to keep him restrained." Interview with R3's physician (MD) 143 on 9/10/13 at 9:40am revealed that R3 was "confused" and that restraints were needed because the resident would try to get up and use the bathroom. MD143 stated that even with side rails and wrist restraints, R3 had managed to fall, by getting his wrist restraint untied and going through the gap between his top and bottom side rails. MD143 stated she did not know "what else we can do," stating the family had told the facility to restrain him when he was admitted , due to his confusion. Further interview with MD143 and MD 142 (who was present during this interview) revealed that neither was aware of the federal regulations regarding restraint use. The physicians were unaware that restraints could only be used to treat medical symptoms and not for staff convenience (such as to relieve fears that a resident might fall.)They stated they did not know that the resident must be assessed by an interdisciplinary team, with the facility attempting less restrictive measures prior to restraint use. Further interview with MD143 on 9/11/13 at 2:58pm revealed that the facility protocol required a new order for restraint use every day. MD143 related she was unaware that there were no orders for multiple days when the resident was restrained, including both days when the resident sustained [REDACTED]. MD143 noted that all orders written by medical students must be co-signed by a physician, and that backdating of orders by a medical student, "is not acceptable practice." Interview with the Administrator on 9/11/13 at 10:45am revealed that the use of fours side rails which block exit from the bed, "is a restraint." The Administrator stated that side rails must be treated like any other restraint and require a physician's order. Further interview with the Administrator revealed that prior to any restraint use, "of course," the resident must be thoroughly assessed. He noted that the facility must make sure the resident actually needed to be restrained, because, "if they don't require a restraint, they are in greater danger," if one was used. 2. Observation during initial tour on 9/9/13 at 10:30am revealed R8 lying in bed and was restrained with four quarter side rails up (one top and bottom rail on each side of the bed). In addition, both of the resident's arms were restrained with soft wrist restraints, which were tied to the bed frame. Interview with the DON during the initial tour on 9/9/13 at 10:30am revealed that R8 was restrained because she was "disoriented." The DON confirmed the resident had side rails up on both sides of her bed and had wrist restraints which kept her tied to the bed because" She's tried to climb over the side rails." Further observation on 9/9/13 at 11:30am, 1:30pm, 2:30pm, and 3:10pm; 9/10/13 at 7:50am, 9:05am, 9:55am, 11:15am, 12:30pm, 1:00pm, and 2:45pm; 9/11/13 at 9:35am, 12:00pm, 12:35pm, and 3:45pm; 9/12/13 at 9:15am, 12:15pm, and 3:15pm; and 9/13/13 at 8:40am, and 10:50am also revealed R8 was restrained in bed with wrist restraints and four side rails Final observation of R8 on 9/13/13 at 1:25pm revealed the resident remained restrained in bed, with both arms tied to the bed frame with the use of soft restraints, and all four side rails in the up position. Review of the clinical record revealed R8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nursing notes dated 7/24/13 revealed from the day of admission, the resident "esta restringindo" (is being restrained). Review of the Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/6/13 revealed Section P (Restraints) was coded to indicate the resident had no restraints, including either side rails or limb restraints. However, review of physician orders and daily progress notes revealed this information was not accurate, as the resident was restrained during the assessment period. Further review of the Resident Assessment Instrument (RAI) revealed the use of restraints had not been assessed through the Care Area Assessment (CAA) process or care planned. (Refer to F272, F278, and F279.) Review of R8's clinical record lacked documented evidence of assessment as to the medical necessity for restraints. The record also lacked documented evidence the facility had attempted less restrictive measures or alternate interventions prior to restraining the resident. Although the DON related the resident had tried to climb over the side rails, there was no documented evidence the facility had reassessed the resident to identify if the restraints presented a risk to R8. Although review of the facility policy revealed that restraints must be reordered every 24-hours, review of R8's clinical record revealed the resident was restrained for multiple days without a physician's order. Review of the clinical record of R8 on 9/13/13 revealed there were no orders after 9/6/13 for physical restraints, (either the soft wrist restraints or four side rails) in the resident's record. The Risk Manager also reviewed the record, and at 8:35am on 9/13/13 confirmed that there were no orders for the resident to be restrained any day after 9/6/13. She related that facility policy required a new physician's order every day, and was unaware, until surveyor intervention, that this resident had been restrained for one week without orders, including on 9/12/13, when she was found entrapped in the side rails, hanging from her wrist restraints. (Refer to F323). 3. Observation of R16 on 9/11/13 at 10:40am revealed the resident was in bed awake with both his wrists and left ankle tied with soft restraints to the bottom of the bed. Observation revealed the bed was equipped with four side rails (one top and bottom rail on each side of the bed) and all four of the rails were in the up position. Observation of R16 on 9/11/13 at 12:00pm and on 9/12/13 at 8:30am revealed the resident's family was in the room and the resident's wrists and left ankle were untied. Observation also revealed all four of the side rails were in the up position and the bed was in a high position approximately 2 and ? feet from the floor An interview on 9/11/13 at 10:45am with R16's family (F) revealed F16 untied the wrists and left ankle restraints when she was in the room. F16 further stated the left ankle was tied because the resident puts his leg through the side rail bars. F16 stated on 8/23/13, the resident had untied his wrist restraints, gone through the gap between the rails, and fallen onto the floor. (Refer to F323) Review of the clinical record revealed R16 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. There was no documented evidence the physician had ordered a restraint for the resident's left ankle restraint or a medical reason for the use of the physical restraints. The resident's MDS assessment was completed on 9/5/13 and revealed the resident was alert and oriented to person, place and time, and had no cognition issues. The assessment further revealed the resident had no falls prior to admission, side rails had been used daily, and limb restraints were used daily during the assessment look-behind period. There was no documented evidence the facility had attempted alternative interventions prior to the use of the side rails or wrist and ankle restraints. Further review of the clinical record revealed the "Plan De Cuidado Interdisciplinario for Caidas" (Care Plan for Falls) did not identify any reason/problem with a potential for falls; however, a goal for falls had been developed. The goal stated the resident would be free from falls and the interventions for the goal included call light in reach, bed in the low position, appropriate lighting, lamp cord in reach, water/personal items within reach, and prevention rounds were to be conducted. Review of the "Plan De Cuidada interdisciplinario for Restricciones Fisicas" (Care Plan for Restraints) did not identify any reason/problems for the use and type of restraint that was applied. The goal for the restraint was to guarantee the security of the resident, decrease the use of the restraint and side rails, and to promote dignity and respect to the resident. There were no documented interventions to achieve the goal for the use of the restraints. Interview with the DON on 9/11/13 at 10:15am revealed there was no medical justification for the use of the physical restraints except to prevent falls. She further stated there had been no alternative attempted prior to the use of the soft wrist restraints and side rails and confirmed there was no physician's order for the use of [REDACTED] 4. Observation of R17 on 9/11/13 at 9:15 am revealed the resident was in bed awake with both wrists tied with soft restraints to the bottom of the bed. Observation revealed the bed was equipped with four side rails (one top and bottom rail per side) and all four of the rails were in the up position. The bed was in a high position of approximately 2 and ? feet from the floor. Further observations of R17 on 9/11/13 at 10:30 am and 1:00pm revealed the resident was in bed with both wrists tied with soft restraints to the bottom of the bed and all four side rails were in the up position. Review of the clinical record revealed R17 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 9/3/13, the resident's physician ordered side rails and soft restraints for the left and right wrist. The reason for the side rails and wrist restraints were to prevent "Caidas" (falls). Further review lacked documented evidence of a medical reason for the use of the physical restraints as well as no documented evidence the facility had attempted alternatives prior to the use of the side rails or wrist and ankle restraints. The resident's MDS assessment was completed on 9/1/13 and revealed the resident required limited assistance from one staff for bed mobility and extensive assistance from one staff for transfers. The assessment did not reveal any falls prior to admission. Review of the "Plan De Cuidado Interdisciplinario for Caidas" (Care Plan for Falls) dated 9/3/13, in the clinical record, revealed the resident had a potential for falls due to his limited level of activity, and decreased cognition. The goal of the care plan was for the resident to be free of falls; however there were no documented interventions to achieve the goal. Review of the "Plan De Cuidada interdisciplinario for Restricciones Fisicas" (Care Plan for Restraints) dated 9/3/13 did not identify any reason/problem for the use and type of restraints that were applied. The goals for the restraint were to guarantee the security of the resident, decrease the use of the restraint and side rails, and to promote dignity and respect to the resident. The interventions were to evaluate the risk of using the restraint or side rails, the reason for the use of the restraint was for fall prevention, and the type of restraint was soft wrist restraints for both arms. There were no documented interventions for the decrease of the use of the physical restraints. Interview with the DON on 9/11/13 at 10:20 am revealed there was no medical justification for the use of the physical restraints except to prevent falls. She further stated there had been no alternatives tried prior to the use of the soft wrist restraints and side rails. 5. Observation of R1 on 9/9/13 at 11:20 am revealed the resident was in bed awake, with the left wrist tied with a soft restraint to the bottom of the bed. Observation revealed the bed was equipped with four side rails (one top and one bottom on each side of the bed) and all four of the rails were in the up position. Further observation of R1 on 9/9/13 at 12:55 pm, 2:20 pm, 3:35 pm, and on 9/10/13 at 7:55 am revealed the resident's left wrist was tied with a soft wrist restraint to the bottom of the bed. Observations also revealed all four of the side rails were in the up position and the bed was in a high position of approximately 2 and ? feet from the floor. Review of the clinical record revealed R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/25/13, the resident's physician had ordered side rails and soft restraints for the left wrist to prevent "Caidas" (falls). There was no documented medical reason for the use of the four side rails nor had documented evidence the facility attempted any other alternatives prior to the use of the side rails or wrist restraints. The resident's MDS assessment was completed on 8/25/13 and revealed the resident had short and long term memory problems. The assessment further revealed the resident had no falls or restraints prior to admission. Review of the "Plan De Cuidado Interdisciplinario for Caidas" (Care Plan for Falls) in the clinical record revealed the resident had a potential for falls due to limited level of activity. The goal of the care plan was for the resident to be free of falls. The documented interventions required the facility to make prevention rounds, and discuss with the family, the acceptance of the safety precaution for the prevention of falls and to assure safe transfers to the wheel chair. There was no documented evidence in the care plan for the use of the physical restraints (side rails and left wrist restraint). Interview with the DON on 9/10/13 at 1:10 pm revealed no alternative had been tried prior to the use of the wrist restraint or the side rails. She also confirmed there was no medical reason for the use of the full side rails nor had a care plan been developed for the use of the physical restraint of side rails and wrist restraint. 6. Observation of R2 on 9/9/13 at 11:23 am revealed the resident was in bed awake with both wrists tied with soft restraints to the bottom of the bed. Observation also revealed the bed was equipped with four side rails (one top and one bottom on each side of the bed) and all four of the rails were in the up position. The bed was in a high position of approximately 2 and ? feet from the floor. Further observation on 9/9/13 at 12:55pm, 1:20 pm, and 2:20 pm; and on 9/10/13 at 7:55 am, 10:01 am, 11:25 am, and 1:38 pm revealed the resident was in bed with both wrists tied with soft restraints to the bottom of the bed and all four side rails in the up position. Review of the clinical record revealed R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]." There was no documented medical justification for the use of the wrist restraints or the side rails. There was no documented evidence that alternatives were attempted prior to the use of the side rails and the wrist restraints. Further review of the record also revealed there was no documented evidence an assessment for the use of the physical restraints (side rails and wrist restraints) had been completed. Interview with the MDS Coordinator (E140) on 9/10/13 at 2:00pm revealed no physical restraint assessment had been completed. Interview with the DON on 9/10/13 at 1:10pm confirmed there were no interventions documented on the falls care plan, and there was no care plan developed for the use of the physical restraints (side rails and wrist restraints). The DON also confirmed there was no medical justification for the use of the restraints. 7. Observation during initial tour on 9/9/12 at 12:20 revealed R10 restrained in bed, with four quarter side rails up (one top and bottom rail on each side of the bed). In addition, the resident's right arm was restrained with a soft wrist restraint tied to the side rail, while the left arm was restrained with a soft wrist restraint tied to the bed frame. Further observation revealed on 9/9/13 at 1:50pm, 3:05pm, 3:45pm; 9/10/13 at 8:00am, 9:05am, 10:00am, 2:20pm; 9/11/13 at 2:30pm, 3:35pm, 4:25pm; 9/12/13 at 8:25am, 8:55am, 10:25am, 10:50am, 11:15am, 12:00pm, 1:45pm, 2:30pm, 3:05pm, 3:50pm, and 9/13/13 at 8:25am, and 9:00am R10 was also restrained with 4 side rails up and wrist restraints Interview with Licensed Practical Nurse (LPN) 36 on 9/10/13 at 8:15am revealed he provided care for R10, and was aware of his status. Interview with LPN36 revealed the resident had full side rails and his arms tied to the bed because of staff fears that the resident would fall if he were not restrained. LPN36 stated R3 was disoriented and staff was afraid he would try to get out of bed if he were not tied down. Review of the clinical record revealed R10 was admitted to the facility on [DATE] for deconditioning syndrome. The resident's [DIAGNOSES REDACTED]. Review of the clinical record also revealed from the day of admission, the resident was restrained with all four side rails in the up position and bilateral wrist restraints. The clinical record lacked documented evidence that consent for the use of wrist restraints was requested or given. Although the clinical record did contain a consent form regarding raised side rails, review of this document revealed consent for the use of side rails had never been received. Further review of the clinical record lacked documented evidence of an interdisciplinary assessment prior to the application of restraint. Additionally, there was no documented evidence that less restrictive measures were attempted prior to the use of two restraints for R10. Review of the daily physician's order on 9/4 - 9/10/13 revealed the behavior which the resident manifested was "incapaz de seguir instrucciones" (incapable of following instructions). According to the order, the reason for restraint use was "prevention of falls." Review of each of the orders confirmed that no less restrictive measures had been considered or attempted prior to restraining the resident each day. Further review of these orders revealed the orders for soft wrist restraints were completed by a medical student on 9/7/13, 9/8/13, 9/9/13, and 9/10/13 and these orders had not been co-signed by a licensed physician. Review of the clinical record revealed that the facility failed to develop a care plan in response to the problem of restraint use for R10. Interview with the MDS Coordinator on 9/13/13 at 10:15am revealed the facility had not identified the need to care plan for residents who were restrained with side rails. However, there was supposed to be a restraint care plan for any resident with wrist or leg restraints. Further interview with the MDS coordinator revealed that a restraint care plan should be developed as part of the initial assessment and care plan process, if the resident will be restrained. 8. Observations of R7 between 9/9 - 9/13/13 revealed the resident in bed with all four side rails (one top and one bottom rail on either side of the bed) in the up position. Review of the clinical record of R7, admitted on [DATE], revealed an MDS with a reference date of 8/27/13 which showed no side rails in Section P for restraints. The MDS was signed as complete on 8/27/13. Review of the physician orders from 8/14/13 through 9/10/13 revealed no orders for the side rails to be raised. Further review of the clinical record revealed it lacked documented evidence that less restrictive measures were attempted prior to restraining this resident. There was no documented evidence that R7 had care plans for restraint use, which was confirmed during an interview with the MDS Coordinator on 9/10/13 at 10:30am. 9. Observation of R12 on 9/11 - 9/13/13, during Phase II of the standard and extended survey, revealed the resident in bed with all four side rails (one top and one bottom rail on each side of the bed) in the up position. R12 was admitted on [DATE] for physical therapy following repair of a left [MEDICAL CONDITION]. Review of the clinical record revealed there were no physician orders for side rails, and no documented evidence that less restrictive measures had been attempted prior to restraining the resident. 10. All observations of R9 between 9/9/13 and 9/13/13 revealed the resident was in bed with all four side rails in the up position, preventing the resident from being able to get out of the bed. Review of the clinical record revealed R9 was admitted to the facility on [DATE] after being transferred from the hospital, status [REDACTED]. Further review revealed "Documentar en nota enfermeria" (Nursing Notes) dated 9/6/13 until 9/11/13 that documented the side rails were elevated. Further review of the clinical record revealed no restraint assessment, care plan, or evidence that less restrictive measures were attempted to prevent falls prior to restraining R9. 11. R4 was admitted to the facility on [DATE] status [REDACTED]. Review of the clinical record revealed an initial nursing assessment, dated on 8/27/13, which stated the resident was alert to time, place and person, was able to understand speech, could be understood, comprehended clearly and did not ambulate. Review of the nurse's notes revealed documentation which reflected the resident had upper and lower side rails elevated on all three shifts between 8/28/13-9/4/13, 9/7/13 and 9/11/13. On 9/5/13, 9/6/13 and 9/12/13, there was a lack of documentation in the record for the use of side rails on the first and second shift. The documentation reflected the resident had upper and lower side rails elevated on the third shift. On 9/8/13, the nurse's notes documented the resident had upper and lower side rails elevated on the first two shifts and lack of documentation on the third shift. There was no physician order for [REDACTED]. Observation on 9/9/13 at 11:00am and 2:55pm, 9/10/13 at 11:00am, 9/11/13 at 11:30, and 9/12/13 at 3:00pm revealed the resident in bed with all four side rails elevated and the bed in the high position. On 9/13/13 at 8:55am, the DON was interviewed regarding the use of side rails for R4. The DON stated she was not aware of why the resident had side rails elevated and was not sure this was considered a restraint. 12. R11 was admitted to the facility on [DATE] with diabetes mellitus type II, [MEDICAL CONDITION], hypertension, status [REDACTED]. Review of the nurse's notes revealed documented evidence the resident had upper and lower side rails elevated between the dates of 8/31/13 through 9/11/13. There was no documented evidence of a physician order for [REDACTED]. On 9/9/13 at 9:30am, 9/11/13 at 1:00pm, 9/12/13 at 9:15am and 4:15pm, the resident was observed with all four side rails elevated and the bed in the high position On 9/13/13 at 8:55am, the DON was interviewed rega | 2014-04-01 |