| 6377 |
GREENBRIER HEALTH CARE CENTER |
515185 |
1115 MAPLEWOOD AVENUE |
LEWISBURG |
WV |
24901 |
2014-06-27 |
152 |
E |
0 |
1 |
35BV11 |
Based on staff interview, observation, review of facility policy, family interview, and resident interview, the facility failed to ensure four (4) of four (4) residents reviewed for rights were afforded the opportunity to exercise their rights. Residents were not free to exercise their rights regarding the use of side rails. Resident identifiers: # 98, #71, #29, and #2. Facility census: 77. Findings include: a) During the survey, residents and family members expressed serious concerns regarding the facility's decision to discontinue the use of side rails. The residents who expressed concern were those who used the side rails for turning and repositioning. An interview with Employee #1 (director of nursing), on 06/24/14 at 9:30 a.m., revealed the side rails were discontinued on 06/11/14 at the request of the medical director. Review of a new policy regarding side rails, which the facility implemented on 06/11/14, revealed the statement, No Resident will have side rails, unless the resident has capacity. Capacity to make health care decisions and the right to use side rails are not one and the same. The decision to discontinue the side rails was not discussed with the resident to judge how well the resident understood the facility's concerns with the use of side rails and/or how the resident used the side rails. Each of the residents for whom concerns were raised were deemed to not have capacity to make health care decisions. The facility also did not allow the person appointed under State law to act on the resident's behalf regarding the use of the side rails. 1) Resident #98 On 06/23/14 at 1:47 p.m., during an interview with Resident #98 and his wife, who acts as the resident's medical power of attorney (MPOA), the MPOA said a couple of weeks ago a facility staff member informed them the resident could no longer use his side rails. The MPOA became visibly upset when discussing the matter. The MPOA stated the facility staff member said, State says we can't use side rails because someone may get their head caught in them. The two (2) 1/4 side rails on the resident's bed were secured in the lowered position with two (2) zip ties on each side rail. The MPOA said Resident #98 could turn and reposition himself independently when the side rails were in the up position. Without the side rails, the resident had to call staff to assist him to turn and reposition. The MPOA said recently the resident had an itch on his back, and they had to use the call light to get staff to help him turn so he could scratch his back. She said the resident was upset by this and told her he did not want to have to push his button every time he had an itch. During the interview, the resident asked if he would again be able to use his side rails. The resident and his wife/MPOA said they were not consulted in the decision regarding discontinuation of the use of the side rails. 2) Resident #71 On 06/25/14 at 3:30 p.m., Resident #71 was observed in her bed. Her side rails were in the down position secured with two (2) zip ties on each side rail. The resident said she wished she still had her side rails because she used them to position herself in the bed. She asked if she would ever get them back. During a telephone conversation, on 06/25/14 at 5:00 p.m., with the MPOA for Resident #71, the Resident's MPOA said she received a letter stating the side rails would no longer be allowed to be used by the residents. She thought the letter came from the State. She said her mother was very upset about losing her side rails, as she was able to turn and reposition independently while in bed. She said her mother no longer feels safe in bed, and now requires assistance to turn and reposition. The MPOA said it was her opinion, as well as her Mother's opinion that she (the resident )could do more and felt safer with the side rails. She said she wanted her mother to once again be able to utilize her side rails. 3) Resident #29 During an interview on 06/17/14 at 4:20 p.m., Resident #29 said her side rails were removed about a week ago. She said she was informed by staff that she could no longer use them. On 06/25/14 at 11:20 a.m., Resident #29 said she almost fell getting out of bed that morning because she did not have her side rail to assist her. Several times during the conversation, she expressed a fear of falling. The resident said she used to be able to get out of bed herself using the side rail and the arm of her recliner. She said she no longer attempts to get out of bed, without staff, due to a fear of falling. The resident said when she had her side rails, she was not fearful of falling. She said her anxiety was higher now because she cannot have her side rails. During a telephone interview with the resident's MPOA, on 06/25/14 at 11:31 a.m., the MPOA said she really believed Resident #29 needed her side rails. She voiced fear for the risk of injury to the resident was greater without the side rails than with the side rails. The MPOA said when she talked with the administrator and expressed her desire for the resident to have side rails, the administrator told her, State says side rails cannot be used, and I just can't go against State rules. The MPOA said the facility made a decision to discontnue the use of side rails regardless of the resident's or the MPOA's wishes. She said she thought the decision made the resident require staff assistance in areas in which she did not previously need assistance. The MPOA also said the entire situation had made the resident's anxiety worse. 4) Resident #2 On 06/11/14 the facility implemented a policy which stated No Resident will have side rails, unless the resident has capacity. An interview with Resident #2, on 06/20/14 at 9:10 a.m., she demonstrated she could raise the bed, but was not able to reposition in bed or raise the head of the bed due to the controls being on the lowered secured side rail. Observation of the resident's side rails revealed the side rails were secured in the lowered position. An interview on 06/24/14 at 9:30 a.m. with the director of nursing revealed there was no assessment completed for Resident #2 prior to implementing the policy and discontinuing the resident's side rails. She stated she had ordered two (2) devices to assist with bed mobility, but they had not yet arrived. She verified the side rails were discontinued prior to the alternative devices being in place. An interview with the medical director on 06/25/14 at 8:00 a.m. revealed residents were to be assessed by physical therapy and alternate bed control and positioning devices were to be in place prior to the discontinuation of the bed rails. She confirmed the facility had not completed the physical therapy evaluations. She also said the facility had not received the positioning devices they ordered. |
2018-04-01 |