cms_PR: 81
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 81 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2018-08-20 | 604 | D | 0 | 1 | 1LG411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to ensure residents (Resident (R) 84 and R88 were free from physical restraints not required to treat the resident's medical symptoms and failed to assess the Residents to ensure the least restrictive alternative for the least amount of time was used. This involved 2 of 10 residents reviewed for bed rails. Findings include: 1. On 08/19/18 at 10:20 AM and 10:50 AM R88 was observed in bed with all side rails up. At 10:50 AM RN3 verified all four side rails were up and stated R88 was not able to put the side rails down. She stated only the staff could put the side rails down. On 08/20/18 at 3:22 PM he was in bed with all four side rails up. During the observation on 08/20/18 at 3:22 PM R88 stated he did not like the side rails up and he wanted them down because they made him feel like he was in Jail. The Active problem list in his electronic medical record (EMR) for R88 indicated his [DIAGNOSES REDACTED]. SNF (skilled nursing facility) admission note for R88 written by the physician and dated 08/15/18 indicated he was admitted to the facility for Physical, Occupational and Recreational therapy after being hospitalized with a DX (diagnosis) of acute UTI (urinary tract infection) and General Weakness. The note indicated the upper bed rails would be elevated for a therapeutic way. R88 had physician's orders [REDACTED]. The plan of care for use of the side rails with a start date of 08/15/18 indicated use of top rails as a therapeutic mode. Review of his Admission MDS with an ARD of 08/19/18 revealed he had a BIMS (Brief Interview for Mental Status) score of 14 at Section C, Cognitive Patterns and required limited assistance with bed mobility and transfers at Section G, Functional Status. The resident's medical record was reviewed in its entirety and revealed no documentation of an assessment for the use of all side rails. On 08/19/18 at 4:20 PM the Director of Quality and Utilization of Medicine verified R88 had not been assessed for the use of the bed rails. 2. On 08/17/18 Resident 84 was observed in bed with all four bed rails up at 11:57 AM and 12:19 PM. During the observation at 11:57 AM Registered Nurse (RN) 2 and Licensed Practical Nurse (LPN)1 were both in the room. Each of the nurses stated they routinely care for the resident. When asked if she moves around they each stated R84 does move around in the bed. On 08/18/18 at 8:45 AM, 9:15 AM, and 10:45 AM and on 08/19/18 at 3:27 PM R84 was observed in her room in bed with the upper and lower bed rails in the up position. There was no observation of the resident attempting to get out of bed or move around in the bed. The mattress fit securely against the bed rails. On 08/18/18 at 2:45 PM LPN2, Physical Therapy Assistant (PTA) 1, LPN3 and LPN4 were interviewed. During interview they each stated they have cared for R84. They all confirmed both the upper and lower side rails are raised when the resident is in bed. They all stated that R84 could get out of bed if the bed rails were down but not safely. PTA1 stated the resident could walk with assistance. The resident's [DIAGNOSES REDACTED]. According her Minimum Data Set Assessment (MDS), an assessment tool used by staff to identify resident care problems and care planning, with an Assessment Reference Date (ARD), end point of the assessment, of 06/06/18 and a completed date of 08/18/18, her cognitive skills for daily decision making were severely impaired at Section C, Cognitive Patterns, and she had balance problems during transfers and walking at Section G, Functional Status. This MDS was found in the electronic record only and was never transmitted. Review of the physician's orders [REDACTED]. On 08/17/18 at 11:57 AM an interview was conducted in the nursing station with RN3 and the Director of Nursing (DON). They both stated they routinely use all four side rails when R84 is bed for her safety. The bed rails have been used since admission over a year and no incidents have occurred. When asked if they had assessed the resident for appropriate alternatives and for a medical reason the Director of Nursing stated, they had not. The resident's electronic and paper medical record was reviewed in its entirety and revealed no documentation of an assessment for the use of the bed rails. The daily nursing notes were reviewed from 08/01/18 to 08/17/18. The nurses documented all up under the State of the Bed Rails column. | 2020-09-01 |