cms_AZ: 98
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 98 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2018-03-30 | 604 | E | 0 | 1 | WXKF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, staff and resident interviews and policy and procedures, the facility failed to ensure that three residents (#68, #20 and #75) were assessed and/or monitored for the use of physical restraints. Findings include: -Resident #68 was readmitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. A physician's order dated (MONTH) 22, (YEAR) included for a Velcro self releasing belt when in wheelchair, due to poor safety awareness. A physical restraint informed consent was completed on (MONTH) 22, (YEAR). The documentation indicated that the restraint being used was a self releasing belt, when in the wheelchair. The documentation included specific target behaviors and that the resident had poor safety awareness. The form was signed by the resident's Power of Attorney (POA). However, an initial restraint evaluation could not be located in the resident's clinical record. There was no clinical record documentation that the resident was assessed for the use of the device, in order to determine if the device was a restraint. Review of a physical restraint evaluation dated (MONTH) 16, (YEAR) revealed the resident had an unsteady gait, agitated behavior, aggressive behaviors, attempts to self-transfer, and climbs out of bed. It was noted that the resident continues to ambulate and get out of bed, without assistance. The evaluation indicated that the restraint (self releasing belt) was effective and to continue it's use. The documentation did not include if the resident was assessed to be able to release the self releasing belt. Another physical restraint evaluation dated (MONTH) 18, (YEAR), included that the restraint (was considered to be effective and would be continued. The documentation did not include if the resident was assessed to be able to release the self releasing belt. Review of the nursing notes revealed that the resident was discharged on (MONTH) 24, (YEAR). The clinical record documentation showed that the order for the Velcro self releasing belt when in wheelchair had been discontinued on (MONTH) 28, (YEAR). The resident was then readmitted to the facility on (MONTH) 31, (YEAR). Review of a current care plan indicated that the resident was at risk for falls related to disease processes. One of the interventions was to apply the Velcro protective device, when up in wheelchair. A physical restraint evaluation was completed on (MONTH) 1, (YEAR). This assessment indicated the resident had an unsteady gait, aggressive behaviors, and attempts to self-transfer. The waist restraint (self releasing belt) was noted to be effective in the past. The assessment indicated that other alternative attempts had been tried prior to using the restraint including a recliner, a companion, one on one activities, a positioning device, regular toileting, and scheduled rest times. The assessment also included that a physician's order had not been obtained for the self releasing belt, but a message was left with the physician on (MONTH) 31, (YEAR) to obtain an order. Review of a quarterly Minimum Data Set (MDS) assessment dated (MONTH) 21, (YEAR), revealed the resident scored a two on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. The MDS did not code the resident as using a physical restraint. Review of the current physician's orders for (MONTH) (YEAR) revealed there were no orders for the use of the Velcro self releasing belt upon the resident's return to the facility. In addition, there was no clinical record documentation of any direct monitoring and supervision which was done, when the self releasing belt was being utilized, and there was no documentation regarding the time and frequency of when the restraint should be released. An interview was conducted with a Licensed Practical Nurse (LPN/staff #101) at 2:22 p.m. on (MONTH) 27, (YEAR). She said that the resident has a Velcro belt on for safety, as he wheels around in his wheelchair and tends to slide down. She said that she did not think it was a restraint for him, because he is able to get up if he wants too. Staff #101 stated that if he tries to get up, the belt will eventually loosen and slide down as he gets up. She said there should be a physician's order for the belt. An interview was conducted with a Certified Nursing Assistant (CNA/staff #107) at 8:30 a.m., on (MONTH) 28, (YEAR). She said that she thinks the resident has the Velcro belt, because he is a fall risk as he tries to get up by himself. She said that he slides up and down in his chair and the belt helps him to stay in the chair. She said that the resident is able to remove it as needed, so she did not think it was a restraint. During an interview with the resident at 10:00 a.m. on (MONTH) 28, (YEAR), he said that he could remove the belt but when asked to remove it, he was unable. An interview was conducted with the unit manager (staff #36) at 11:40 a.m. on (MONTH) 28, (YEAR). She said the belt is not a restraint for the resident, because they only use them if residents are able to remove them. She said that he might have moments where he is angry or agitated and he will not display that he knows how to remove it, but removes it later. She stated that he has removed the belt from time to time and has fallen. She said that she checks the belt at least weekly to make sure it is applied correctly and is in good shape. She said if he tries to stand up the belt will loosen, but will do so slowly, so that staff are able to get to him before he falls. Staff #36 stated that the belt is helpful, because the resident constantly leans forward. She said the process for obtaining a device like the belt is to obtain a physician's order and then get consent from the family. After reviewing the chart, staff #36 stated that there was no order probably because he had gone out of the facility and come back. She said they do not use restraints in the facility. She said that she did not know much about the physical restraint assessments in the computer charting system. During an interview with the Director of Nursing (DON/staff #18) at 11:15 a.m. on (MONTH) 29, (YEAR), he said that the process regarding safety devices is that when the need for such a device arises, the interdisciplinary team will meet and discuss which device to use for a resident. He said they will talk about what they have done prior to using the device and the reason behind using a device. He said that once they decide to use a device, they will apply the device and then discuss it from time to time to determine if it should be discontinued. Staff #18 said that currently, they are not looking at devices such as this resident's Velcro belt as a restraint and they do not go through all of the documentation that is required for a restraint, including removing it every 2 hours and documenting the removal on the TAR. He said that this has changed in the facility, as they used to consider some of these devices as restraints. He said that he is not aware of an assessment to determine if a device is a restraint or not, but they do discuss this. Another interview was conducted with staff #18 at 10:00 a.m. on (MONTH) 30, (YEAR). He said the facility previously used a pre-restraint assessment to determine if a device was a restraint, but they stopped using this form since they no longer consider these devices as restraints. Staff #18 stated that he understands the facility should assess to determine if a device is a restraint, but currently they are not doing this. He said there should be an order for [REDACTED]. -Resident #20 was admitted (MONTH) 28, 2011, with [DIAGNOSES REDACTED]. A physician's order dated (MONTH) 29, (YEAR) included for a lap buddy when the resident is in the wheelchair for positioning, due to left-sided weakness related to a [MEDICAL CONDITION]. Review of the clinical record revealed there was no documentation that the resident was assessed for the use of the lap buddy, in order to determine if the device was a restraint for the resident. There was also no documentation that the resident/responsible party had been notified of the risks and benefits of the lap buddy. A quarterly MDS assessment dated (MONTH) 27, (YEAR), revealed the resident had a BIMS score of 9, which indicated the resident had moderate cognitive impairment. The MDS included the resident had been assessed to require extensive assisstance with bed mobility, transfers, locomotion on the unit and was totally dependent on staff for locomotion off the unit. The MDS further documented that the resident had limited range of motion to upper and lower extremities. The MDS did not code the resident as using a restraint device. Review of the current physician's orders for (MONTH) (YEAR) revealed orders for a lap buddy when the resident is in the wheelchair for positioning, due to left-sided weakness related to a [MEDICAL CONDITION]. A physician's order dated (MONTH) 25, (YEAR) included for an occupational therapy evaluation for her wheelchair. Review of the Occupational Therapy evaluation dated (MONTH) 26, (YEAR), revealed the resident was in a high back wheelchair and was not in a good position, which will cause falls. The evaluation included that the resident should be seen by a company that will fit the resident with a wheelchair which will put her in a good position to prevent falls and pressure ulcers. The evaluation did not address the use of a lap buddy. Observations were conducted of resident #20 on (MONTH) 26, (YEAR) at 10:00 a.m., on (MONTH) 28, (YEAR) at 11:32 a.m., and on (MONTH) 20, (YEAR) at 8:44 a.m. During these observations, the resident was observed to be in a high back wheelchair, with a lap buddy applied. Further review of the clinical record revealed there were no ongoing assessments which were completed, in order to determine if the lap buddy was a restraint and for the continued need for the lap buddy. In addition, there was no documentation regarding any direct monitoring and supervision which was provided during its use, nor the frequency of when to remove the device. An interview was conducted with a LPN (staff #27) on (MONTH) 28, (YEAR) at 11:46 a.m. Staff #27 stated that he had seen resident #20 attempt to remove the lap buddy but was unable too. An interview was conducted on (MONTH) 30, (YEAR) at 9:00 a.m. with a CNA (staff #70), who stated that he provided care to resident #20. Staff #70 stated that he applies the lap buddy, but has not seen the resident take it off. Staff #20 stated the resident has asked for staff to reposition her, as the lap buddy was pressing on her babies. Staff #70 stated the only time he has removed the resident's lap buddy was when he assisted the resident to bed. An interview was conducted with staff #18 on (MONTH) 30, (YEAR) at 9:56 a.m. Staff #18 stated that since the resident could not release the lap buddy, then it would be considered a restraint device that would need to be evaluated. -Resident #75 was admitted on (MONTH) 12, 2013, with [DIAGNOSES REDACTED]. A physician's order dated (MONTH) 5, (YEAR) included for a geri-chair as needed for safety and comfort. A review of the resident's care plan revealed the resident requires a geri-chair to promote functioning at the highest practicable level. The need for this level of intervention is related to [MEDICAL CONDITIONS] and bilateral lower extremity weakness. Interventions included to assess the resident to determine the most enabling, therapeutic and least restrictive treatment approaches. Consider factors such as behavioral symptoms, fall risk, medical symptoms, and ADL self-performance. Emphasize quality of life: confer with the attending physician and IDT members to evaluate alternative devices and least restrictive interventions; evaluate the resident's response to the restraint and share this evaluation with the IDT; advocate for increased quality of life through minimal use of restrictive devices; monitor and report to the physician the following restraint related issues (increased behavior/mood problems, decreased mobility, development of contractures, skin problems, increased incontinence; increased risk of falls) and offer sensory and social stimulation at intervals throughout the day with particular emphasis on the restraint release periods. This care plan was updated on (MONTH) 8, (YEAR). Review of the clinical record revealed there was no documentation of any evaluations which had been completed from (MONTH) 5, (YEAR) through (MONTH) (YEAR), in order to determine if the use of a geri-chair would be a restraint for the resident, and there was no documentation of any medical symptoms that warranted its use. There was also no documentation of the least restrictive measures which were utilized, prior to implementing a geri-chair and that the resident/responsible party had been notified of the risks and benefits of using a geri-chair. In addition, there was no documentation regarding any direct monitoring and supervision which was provided when utilizing the geri-chair, nor the frequency of when to remove the device. According to a quarterly MDS assessment dated (MONTH) 28, (YEAR), the resident was assessed with [REDACTED]. The MDS did not identify the use of a restraint device. Observations were conducted of the resident on (MONTH) 27, (YEAR) at 8:30 a.m., on (MONTH) 27, (YEAR) at 11:30 a.m., and on (MONTH) 29. (YEAR) at 11:30 a.m. During these times, the resident was observed to be seated in a geri-chair. During an interview with staff #18 on (MONTH) 28 (YEAR) at 12:03 p.m., staff #18 stated that any device could be considered a restrictive device and should be assessed as to whether or not it's a restraint and monitored on a regular basis for effectiveness and should be the least restrictive option. An interview was conducted on (MONTH) 29, (YEAR) at 12:18 p.m., with the unit manager (LPN/staff #22) regarding potential restraint devices. Staff #22 stated that the residents (#20 and #75) can't get up from their wheelchairs, so the devices are not restraints and therefore, they do not need assessments. A follow-up interview was conducted with staff #18 on (MONTH) 30, (YEAR) at 9:56 a.m. Staff #18 stated that upon receipt of a physician's orders for devices such as a geri-chair or lap buddy, the order needs to include a medical symptom, and the resident needs to be evaluated or screened by therapy to assess for the need and safety of a potential restraint device. Staff #18 stated that at least quarterly, the IDT teams should evaluate for the continued use of the device, and if the device was determined to be a restraint, then informed consent should be obtained after explaining the risks and benefits of the restraint to the resident/representative. Staff #18 said that staff would need to monitor the use of the devices at least every 2 hours for appropriate application and release of the restraint if appropriate. Regarding resident #75, staff #18 stated that the use of a geri-chair was the resident's choice, however, there was no documentation of that and there were no assessments or evaluations. Staff #18 further stated that the MDS assessments were not coded for residents having restraint devices, as staff had determined that there were no restraints in the building and that all the devices were to be considered mobility devices, even though a resident can not use a geri-chair or lap-buddy to assist with mobility. A review of the facility policy regarding physical restraints revealed to ensure that residents were using the least restrictive restraint and that residents have been assessed for the need of a restraint for safety. The policy stated the nursing staff will evaluate the need for a restraint by trying the least restrictive device possible. If nursing staff are unsure, they will consult with physical therapy and the medical doctor. The MDS coordinator will review physical restraints quarterly along with the care plan review. The policy further included that restraints include, but are not limited to the use of chair alarms, hand mitts, soft ties or vests, wheelchairs, geri-chairs, self-release seat belts, side rails and lap buddies. Practices that meet the definition of a restraint include but are not limited to using devices (e.g., trays, tray tables, bars or belts) that a resident can not remove easily and that prevent the resident from rising when used in conjunction with a chair or wheelchair. The policy also noted that restraints will only be used after alternative methods have been tried, unsuccessfully and upon the written order of a physician which specifies the circumstances (medical symptoms) for the use of the restraint. The order should also include the type of device and the length of time to be used. The need for restraints will be re-evaluated at least quarterly to determine if continued restraint use is necessary to treat the resident's medical symptoms. | 2020-09-01 |