| 7342 |
WINDSOR MANOR |
425114 |
5583 SUMMERTON HIGHWAY |
MANNING |
SC |
29102 |
2013-06-06 |
221 |
E |
0 |
1 |
43K911 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observation, interview and review of the facility provided policy for restraints, the facility failed to assess Resident # 51 for the least restrictive device; failed to apply a clip, soft belt restraint appropriately; used leg restraints with with a Broda chair without a physicians order; and failed to promptly identify and provide intervention for documented risks associated with restraint use. (1 of 3 sampled residents reviewed for restraints) Cross refer to F 272 as it relates to the failure to complete assessments for all restrictive devices used and failure to to accurately complete a siderail assessment. Cross refer to F-280 as it related to the failure of the facility to include all the restrictive devices used for the resident in the resident's plan of care and failure to include all recommended actions to prevent reoccurrence in the plan of care. Cross refer to F 323 related to the failure of the facility to identify the hazards associated with restraint use. The findings included: On 6/5/13 at 8:15 AM, Resident # 51 was observed in his/her room seated in a wheelchair next to the bed. A soiled clip, soft belt was around the resident's waist, clipped in the back and one string of the restraint was securely tied to the right rear anti-tip bar in the rear of the chair. A Certified Nursing Assistant (CNA) was observed as s/he transferred the resident without assistance from the wheelchair to the bathroom, from the bathroom to the wheelchair and reapplied the restraint in the same manner. At approximately 8:30 AM, the resident was observed in the dining room area. The soiled, clip, soft belt remained clipped in the back of the chair and tied to the anti-tip bar. Following the observation, an interview was conducted with the Unit Manager and the Minimum Data Set Coordinator as to how a CNA would know the level of care a resident required and the individual needs of a resident. It was explained to the surveyor that this information is provided in daily report but the CNA's could also review the resident's careplan. On 6/5/13 at 10:45 AM Resident # 51 remained seated in the wheelchair by the TV, the bed/chair alarm was not in place, and the restraint tied to the rear of the wheelchair. On 6/5/13 at 1:41 PM, during an interview with the MDS Coordinator, s/he initially stated that restraint assessments are only completed for comprehensive assessments and are not completed quarterly. When asked if a resident had a fall, would an assessment be done and the reply was yes. However, there were no restraint assessment(s) for any device located in the medical record. On 6/5/13 at 1:58 PM, the MDS Coordinator stated no restraint assessment was located located and the chart has not been thinned. At approximately 4:40 PM, assorted pages from a thinned record were located in a file cabinet but did not include assessments related to the use of any restraint including the Broda chair, lap belt, soft waist restraint, or leg restraint. One assessment form with the resident's name was located but was incomplete except for the resident's name. On 6/5/13 at 2:15 PM a chart review revealed not all orders were written for the initiation of restraints. There were orders to discontinue an abdominal binder but no order to initiate the binder. An order was written to discontinue leg restraints but no order to apply the leg restraints. The Unit Manager verified the findings after reviewing the medical record with the Surveyor present at approximately 3 PM. (On 6/6/13, it was noted the orders were not present on the chart.) At 3:21 PM, the resident was observed in his/her room, the bed/chair alarm attached and the soiled,clip, soft belt applied as previously described. No staff was present in the room, the door was closed, and another resident responded to the request to enter the room. On 6/6/13 at 10 AM, Resident #51 was observed in bed. The call bell was in the resident's wheelchair, out of the resident's reach,and the bed/chair alarm still attached to chair. Resident # 51 was awake, reaching for wheelchair but unable to reach it. A CNA was providing care to the resident in the next bed was notified by this surveyor and advised the resident to wait for assistance. CNA #1 verified the call light was in the wheelchair and out of the resident's reach. S/he confirmed the bed/chair alarm was still in the resident's chair and was not sure if it should be on when in bed since the resident also has a mat bed alarm. This Surveyor observed staff to transfer the Resident with assist of 2 from the bed to the wheelchair and the bed alarm did not sound when resident stood as verified by the two CNA's present. A subsequent interview with the Maintenance Director revealed when the alarm was checked for malfunctioning, it was discovered that inside the battery box was a switch that would silence the alarm and that was why the alarm did not sound. The resident was then assisted to the bathroom. After leaving the bathroom, CNA # 1 was observed reapplying soiled waist restraint, and again securing it to the anti tip bar. When questioned as to why, s/he stated so s/hecan't get out of it. When asked if the device was applied appropriately, s/he stated no. The facility Administrator was present during the interview, and s/he also questioned the CNA. The CNA again explained if it wasn't tied, the resident would get out of it. The Administrator instructed the CNA not to apply the restraint that way and as the CNA untied the straps, s/he stated . gonna fall. The Administrator also verified the soiled restraint and provided a clean restraint for application. Additional record review revealed the resident was admitted to the facility on [DATE] in the late afternoon with a known history of falls. On admission, the resident had order to apply full, bilateral siderails to assist with turning and positioning. On 12/19/12 at 1 PM, a nurses note stated: Res.(resident) cont.(continues) to make several attempts to get oob. (out of bed) Res. attempting to climb over side rails, res. placed in recliner chair , placed at nurses station. Res. attempted to get out of recliner chair. Res. climbed over the side of the recliner chair and fell to floor on buttocks order received for low bed. Resident placed in bed with siderails up x 2 .continues to make several attempts to get oob. Resident turned horizontally in bed with legs over siderails. Resident placed back in recliner. 12/20 /12 8:30 AM, : .in bed, siderails up x 2, attempting to climb oob with legs hanging over siderails. There was no documentation of the use of a low bed as ordered on [DATE] until 12/20/12 at 7:15 PM. A siderail assessment was documented as completed on 12/18/12. The assessment documented the resident had behaviors of anxiety, was at great risk for falls required assistance for bed mobility, transfers and was unable to sit. The resident was documented as needing assistance to turn and move and was unable to use the call system. However, the assessment documented the bilateral padded siderails would be used when in bed for turning and positioning. On 3/27/13 the siderails were documented as being reassessed and stated quarterly review - no changes. On 3/27/13 the resident was using a low bed without siderails in place. On 6/6/13, when questioned, the MDS coordinator stated s/he missed it. On 1/28/13 a nurses note stated leg restraints removed as ordered. No order was found for the use of leg restraints. When interviewed, the facility staff stated the Broda chair used for the resident came with leg restraints and the resident had an order for [REDACTED]. Additional chart review concerns related to the use of restraints for Resident # 51 Nurses noted documented the following: 12/21/12 PM - Attempted to redirect resident without much improvement. Removed from activity area and allowed resident to have privacy and quiet time in own room. No improvement seen in behaviors when secluded. 12/22/12 Moving about in gerichair. Attempting to crawl out of chair. 01/11/13 Resident climbed out of Broda chair and fell on floor on his knees .placed back in to Broda chair with leg straps applied 01/26/13 Resident had taken bed/chair alarm off and had gotten out of Broda chair. Small cut to right side of head and complained of rib pain. 01/28/12 New orders to discontinue Broda chair leg restraints 03/15/13 Found resident on floor. Another resident stated the resident removed his alarm, and slipped waist belt over his/her head and climbed out of chair. 03/22/13 Will pull restraint up and attempt to slide underneath. 03/30/13 Resident weaker and can no longer stand up by himself 04/11/13 Continues to take bed/chair alarm plus taking restraint up over head. 04/12/13 Resident attempting to slide beneath waist restraint 04/16/13 Tries to slip out of waist restraint if not observed closely 04/22/13 Continues to try to get out of waist restraint 04/24/12 Found on floor, waist restraint very loose 05/17/13 Continues to attempt to get out of wheelchair by sliding under waist restraint. Additionally, record review revealed the resident traumatically removed the gastric tube on 12/22/12 and on 12/23/12 an abdominal binder was put in place. An order to discontinue the binder was written on 12/24/12 without further explanation. On 6/5/13 during medication pass observation, an abdominal binder was observed in place. There was no order noted and no other documentation related to its use noted. When observed on 6/6/13 the abdominal binder was not in place. On 6/5/13, in an interview with Licensed Practical Nurse #1, s/he stated when the resident returned to the facility on [DATE], an abdominal was in place. S/he stated s/he left the binder in place and relayed the information to the Unit Manager as s/he was uncertain if it should be continued or not. Review of the resident's careplan initiated on 1/1/13 revealed not all restraints used for the resident were noted on the plan of care. The careplan noted the use of the Broda chair, Broda chair with waistbelt and wheelchair with waist belt. The Care plan did not address the documented use of a Geri chair with/without table, abdominal binder or the use of the leg restraints. The careplan also included the approaches to encourage resident to remain in supervised areas when out of room; Keep call light within easy reach while in room; and instruct resident how to use call bell and call for assistance as needed. During an interview with the MDS Coordinator,s/he verified not all the devices were listed and that some approaches were not suitable for a resident with significant cognitive impairment. A copy of the facility provided policy for restraints stated restraints would be used only after alternatives had been tried unsuccessfully. A restraint should be the least restrictive device. Restraints are of the type that can be easily removed . Restraints should be reevaluated at least quarterly. The residents careplan must indicate the continued use of the restraint has been reevaluated. The Manufacturers instructions for the use of a quick release cushion belt stated: (under contraindication for use) Do not use this device for a patient who: slides down in the wheelchair, has a history of easily removing belt-style,vest style and poncho style restraints, is in a bed, gerichair or lounge chair. This device is intended for wheelchair use only. Never place a patient wearing a restrictive device in a place where s/he is not easily monitored. On 6/6/13 the collected information was reviewed with the facility Corporate consultant who did not dispute the surveyors concerns related to the use of restraints for Resident # 51. |
2017-03-01 |