cms_HI: 20
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 20 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2017-04-21 | 221 | D | 0 | 1 | 1M3411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview with staff members, the facility failed to ensure a resident, Resident #63 was free from a physical restraint. Finding includes: On 4/10/17 at 11:30 [NAME]M. observed Resident #63 in the activity room. The resident was seated in a wheel chair with a gait belt looped through the bars on the sides of the wheelchair and buckled across her lap. Subsequent observation at 11:42 [NAME]M. found the gait belt still buckled across the resident's lap. At 12:21 P.M. Resident #63 was observed eating lunch at a table with the gait belt still affixed to her wheelchair. On the morning of 4/11/17 Resident #63 was observed eating her breakfast in the activity/dining room, the gait belt was affixed to her wheelchair. Subsequent observation at 10:06 [NAME]M. found the resident watching the entertainment. The resident was seated on a bench in the front row. On 4/11/17 at 2:22 P.M. observed Resident #63 asking Staff Member #110 to take her back to the room. Resident #63 was seated in a wheelchair and observed to be wearing a seat belt that was buckled in the front. Resident #63 was observed to self-propel the wheelchair with her feet. The seat belt was removed by the staff member, Resident #63 was observed to stand and walk to the bathroom independently. The resident stood in front of the toilet and started pulling her pants down, at this time, the staff member requested to have the door closed. Second observation at 3:06 P.M. found Resident #63 ambulating on the unit with the assistance of a staff member. Observation from 3:14 P.M. through 3:34 P.M. found Resident #63 propelling herself in the wheelchair around the unit. The seat belt was applied. On 4/12/17 at 8:03 [NAME]M. Resident #63 was observed eating breakfast in the activity/dining room, the seat belt was not applied and there was no gait belt looped across her lap. Subsequent observation at 9:04 [NAME]M. found the resident's seat belt was affixed. A record review done on the morning of 4/12/17 found a physician's orders [REDACTED]. The reason for the use of device is dementia with anxiety and left foot weakness secondary to TIA, gait instability. The form documents that the device is a restraint; however, the team checked that the front buckle belt is not a restraint because the: resident can ask to have it removed; resident can remove it on his/her own; and resident cannot get up on his/her own so is not being restrained. There is no documentation of an assessment for the use of a gait belt to be looped through the sides of the wheelchair as a possible restraint. A review of the Minimum Data Set for significant change with an assessment reference date of 1/9/17 codes daily use of trunk restraint. In Section [NAME] Activities of Daily Living Assistance, Resident #63 was coded as requiring extensive assistance with two person physical assist for transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) and walk in room and corridor as being totally dependent with one person physical assist. A review of the care plan for restraint was updated on 1/20/17 for the use of front buckle belt. The interventions included: when restraint in use, check q 1 hour and release q 2 hours and inspect skin, circulation and movement; release restraint during activities as appropriate; monitor resident's response to restraint; reposition q 2 hours and as needed; and ambulate with 2 person assistance as tolerated. On 4/12/17 at 1:31 P.M. an interview was conducted with Staff Member #155. The observation of the use of the gait belt looped through the side bars across the resident's lap was shared with the staff member. The staff member reviewed the physician order [REDACTED]. Subsequently an interview was conducted with Staff Member #85. The staff member reported the gait belt is not used to be looped over the resident's lap, the gait belt is kept in the resident's wheel chair for tactile purposes. The staff member further reported the gait belt is not to be used to loop across the resident's lap and the use of the gait belt is to assist the resident to ambulate. On 4/12/17 at 1:44 P.M. concurrent observation of the resident was done with Staff Member #155. The resident was asked to unbuckle the seat belt, the resident grabbed the buckle and stated that it was stuck. Resident #63 was unable to remove the front belt buckle. An interview was done with Staff Member #112 on 4/12/17 at 1:40 P.M. The observation of the use of the gait belt was shared with the staff member. The staff member commented that the gait belt was utilized as a restraint and it should not be used in that manner. An interview was conducted with the staff member providing direct care, Staff Member #28 on 4/11/17. The staff member reported the gait belt is not to be used across the resident's lap, the gait belt is kept in the wheel chair so the resident can play with it. The staff member denied applying the gait belt to the wheelchair and stated it may have been the night staff that applied the gait belt to the wheel chair. The facility failed to ensure Resident #63 was free of a physical restraint as evidenced by the use of a gait belt looped through the bars on the sides of the wheelchair and over the resident's lap without an assessment and plan of care. | 2020-09-01 |