cms_PR: 85
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 85 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2018-08-20 | 700 | 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 assess the residents prior to the installation of bed rails; failed to review the risk and benefits of the bed rails with the residents or resident representatives and failed to obtain informed consent prior to installation of the bed rails. This deficient practice affected three residents (Residents(R)84, R86, and R88) of 10 residents sampled for the use of bed rails. Findings include: 1. On 08/17/18 at 11:57 AM and on 08/18/18 at 10:44 AM and at 12:37 PM R88 was observed in his bed with his upper/top side rails in the up position. On 08/19/18 at 10:20 AM and 10:50 AM the resident was observed in bed with all side rails up. The mattress fit tightly against the side rails. No gaps were observed between the side rails and the mattress. At 10:50 AM the RN3 verified all four side rails were up and stated R88 was not able to put the side rails down independently. She stated only the staff could put the side rails down. On 08/20/18 at 9:53 AM he was observed with the top side rails up. On 08/20/18 at 3:22 PM he was in bed with all four side rails up. 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 health record stated his [DIAGNOSES REDACTED]. SNF admission note written by the physician and dated 8/15/18 stated 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. The fall risk assessment in the dated 08/18/18 stated he was at high risk for falls. R88 had physician's orders [REDACTED]. Review of his Admission MDS with an assessment reference date of 08/19/18 revealed he had a Brief Interview for Mental Status (BIMS) (a cognitive evaluation) score of 14 at Section C, Cognitive Patterns indicating he was not cognitively impaired. The MDS indicated he 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 the bed rails, that staff had reviewed the risk and benefits of the bed rails with the resident or resident representatives and that facility staff had not obtained an informed consent prior to installation of the bed 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 and that the risk and benefits of the bed rails had not been explained to the resident nor the resident's representative and that informed consent had not been obtained. 2. On 08/17/18 R84 was observed in bed with all four bed rails up at 11:57 AM and 12:19 PM. On 08/18/18 Resident 84 was observed in her room in bed with the upper and lower bed rails in the up position at 8:45 AM, 9:15 AM, 10:45 AM during each observation the bed was at a regular height. On 08/19/18 R84 was observed in bed with the top side rails up and the bottom bed rails down at 10:55 AM, 11:02 AM, 12:40 PM, and 2:07 PM. On 08/19/18 at 3:27 PM she was observed in bed with all four-bed rail up. On 08/20/18 at 9:58 AM she was observed in bed with just the top rails up. There was no issue with the mattress fitting the bed tightly against the side rails. No gaps were noted between the side rails and the mattress. There was no observation of the resident moving around in the bed or attempts to get out of bed. The resident's [DIAGNOSES REDACTED]. Review of her plan of care with a start date of 03/06/17 for R84 revealed she had a care plan identifying her as high risk for falls. According her MDS with an Assessment Reference Date (ARD), end point of the evaluation period, 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. 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. When ask if they had assessed the resident for appropriate alternatives and for risk of entrapment prior to using the bed rails, the Director of Nursing stated they had not. She also confirmed she had no written documentation to prove the risk and benefits of the bed rails had not been reviewed with the resident's representative and she had no documentation of informed consent. The resident's medical record was reviewed in its entirety and revealed no documentation of an assessment for the use of the bed rails, that staff had reviewed the risk and benefits of the bed rails with the resident or resident representatives and that facility staff had not obtained an informed consent prior to installation of the bed rails. 3. On 08/17/18 at 10:57 AM R86 was in his room with the top bed rails up. The bed rails and the mattress fit tightly and there were no gaps noted. On 08/17/18 R86 was interviewed from 2:00 PM to 2:20 PM. During the interview he had the top side rails in the up position. He had lower rails on the bed however they were not up. When ask if they ever put the lower side rails up he stated they do put them up if they are going to be leaving him a lone for a long period of time. On 08/19/18 at 12:37 PM and 3:30 PM he was in bed with the top bed rails up. According to the active problem list in R86's EMR included [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of his admission MDS with an assessment reference date of 08/12/18 revealed he had a BIMS Score of 15 at Section C, Cognitive Patterns. R86' medical record was reviewed in its entirety and revealed no documentation of an assessment for the use of the bed rails, that staff had reviewed the risk and benefits of the bed rails with the resident or resident representatives, and that facility staff had not obtained an informed consent prior to installation of the bed rails. On 08/19/18 at 4:20 PM the Director of Quality and Utilization of Medicine verified the resident had not been assessed for the use of the bed rails and that the risk and benefits of the bed rails had not been explained to the resident nor the resident's representative and that informed consent had not been obtained. | 2020-09-01 |