Medford Multicare Center for Living
February 22, 2018 Complaint Survey

Standard Health Citations

FF11 483.10(e)(1); 483.12(a)(2):RIGHT TO BE FREE FROM PHYSICAL RESTRAINTS

REGULATION: §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 22, 2018
Corrected date: April 20, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review during an abbreviated survey (Complaint # NY 418), the facility did not ensure that one (Resident #2) of three residents reviewed for physical restraints was assessed to determine whether physical restraints were indicated to treat a medical symptom prior to implementing the use of seat belts on his wheelchair. Specifically, Resident #2, who had impaired cognition, Spastic Quadraparesis and [MEDICAL CONDITION] (CP), was utilizing a wheelchair that was received from his previous residence with two different seat belts mounted on the wheelchair. The facility did not ensure the resident was assessed by a qualified professional for use of the seat belts to determine that the seat belts were physically restraining; did not document consideration of less restrictive devices; and did not obtain a physician's orders [REDACTED]. The findings were: The Facility policy (Undated) titled Tender Touch Policy and Procedure documented that patients in the facility will be screened for positioning needs as indicated. Patients requiring intervention will have a physician's orders [REDACTED]. A Tender Touch Rehabilitation Positioning Evaluation will be utilized and included in the medical record. The procedure also documented that patients will be screened by an Occupational Therapist (OT) for positioning needs. The Facility policy dated 08/20/2012 titled Management and Assignment of Wheelchairs documented; wheelchairs are assigned, repaired and maintained throughout a patient/resident stay. A permanent wheelchair will be assigned by the Rehabilitation Department. During the first therapy session the Rehabilitation Department assesses the wheelchair to ensure that it meets the requirements of the patient/resident. If necessary, the wheelchair is changed or modified. The medical record lacked evidence of the Rehabilitation Department having evaluated Resident #2's wheelchair. The Facility policy dated 04/16/2013 titled Restraint documented: -The responsibility of a Licensed Nurse was to identify the resident's need for possible restraint. -Review medical record to determine alternate methods had been attempted and deemed ineffective. -Implement alternate measures to keep resident safe and document resident's response. -Address resident's risk factors and if deemed necessary the Nursing Supervisor must notify the MD of the need for a restraint in the event the resident is in immediate risk of injury to self or others. -Implement restraint as per MD order. The order must include the restraint type, released schedule, including meal times where indicated and or skin checks. -The Nursing Supervisor is to notify the Nursing Risk manager via Sigma Care (Electronic Medical Record) that a restraint may be needed, initiate interdisciplinary team meeting to discuss the need for the resident restraint if other alternative measures have been deemed ineffective. -Initiate restraint reduction trials at least quarterly and document results in the medical records. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS-an assessment tool) dated 01/13/2018 documented Resident #2's cognitive skills for daily decision making as severely impaired. Resident #2 utilized wheelchair for mobility. The MDS lacked documented evidence of use of restraints. The Comprehensive Care Plan (CCP) dated 01/25/2018 titled Restraints Safety documented use of devices that included: Velcro seat belt and seat belt. Indicators for restraint use included; total loss of trunk control, unaware of functional limitations and contractures. Documented interventions included; release the restraint every two hours for fifteen minutes to toilet/pad changes, skin care, range of motion, reposition. It further documented that the resident needed seatbelt secondary to poor trunk control. The medical record lacked evidence of a physician's orders [REDACTED]. and lacked evidence of less restrictive methods and goals to decrease the use of the restraint. The Resident Nursing Instructions (CNA (Certified Nurse Aide) Instructions) dated 01/08/2018 - 02/05/2018 lacked documented evidence for use of the seatbelts. The Rehabilitation Screen/Referral Form dated 01/09/2018 documented Resident #2 was screened status [REDACTED]. The resident's (prior residence) was providing a personal wheelchair. The Screen/Referral Form lacked documented evidence of evaluation of use of assistive devices including the seat belts. The Occupational Therapist (OT) was interviewed by phone on 02/13/2018 at 9:30 AM. The OT stated that newly admitted residents were evaluated by PT/OT department and the OT evaluated residents for their positioning. The OT stated that the wheelchair for Resident #2 from the prior residence was not yet in the facility when she evaluated the resident. She did not evaluate Resident #2's chair and was unaware when it arrived. She did not think she needed to look at the chair because it was Resident #2's own custom chair. The OT stated that she was not informed that a harness (a Velcro strap around the trunk) and a seatbelt was used for positioning until the chair was sent down for repair after 02/05/2018. The OT stated that she believed that a doctor's order was not required for positioning devices. She did put an order for [REDACTED]. The Director of Rehabilitation was interviewed by phone on 02/13/2018 at 9:50 AM and stated if the chair was provided from the prior residence, the evaluating therapist should evaluate the chair. The Director of Rehabilitation stated that a PO was required for a seat belt use even if it was for positioning. The Director of Rehabilitation was again interviewed on 02/14/2018 at 1:09 PM and, contrary to his statement from the previous interview and to the written PO, he stated that the customized chair with seatbelts for positioning did not require a PO because the resident used it prior to coming to the facility and that the PO (that documented an order) for the use of the wheel chair from the previous residence also implied use of seat belts present on the wheelchair. The Director of Rehabilitation did not evaluate Resident #2's wheelchair and was not aware of the seatbelts use by the resident. The Clinical Care Coordinator (CCC) #2 was interviewed on 02/14/2018 at 9:54 AM; she stated she initiated the Restraint care plan on 1/25/18 for Resident #2 because she was informed by the LPN that resident had a seat belt but did not have a care plan for it. There was no order for a seatbelt and she did not call to get an order. CCC #2 notified CCC #3 who told her she would take care of it. CNA #6 was interviewed on 02/14/2018 at 12:32 PM and stated, when Resident #2 first came, she noticed the seatbelts and spoke to the CCC #3 about them. The Director of Rehabilitation came up and looked at the resident's chair with the two belts. He told CNA #6 about the seat belts, that one was were for trunk control and one was so he didn't slide from the chair, and gave her instructions on how to apply them. CCC # 3 was interviewed on 02/14/2018 at 10:53 AM and stated Resident #2 had a seatbelt for positioning and a Velcro strap that went around the chest for positioning and trunk control. CCC #3 oversees all the residents' care plans on her unit. She did not notify PT/OT when Resident #2's chair with two seat belts arrived from the prior residence. The PT/OT should have been made aware to assess for safety. She saw Resident #2's chair, and the straps. She should have also made sure that there was a PO in place for seatbelt and Velcro strap. She was unsure of the facility policy and procedure regarding use of seatbelts. An interview with the Director of Nursing (DON) was conducted on 02/14/2018 at 1:40 PM. She stated a wheelchair should be checked and assessed by the Rehabilitation Department when a chair came from another residence. The DON stated that the facility should be assessing any devices on the wheelchair and if the Rehabilitation Department deemed the positioning devices appropriate and safe then a PO should be obtained and care plan should be developed. 415.4(a)(2-7)

Plan of Correction: ApprovedMarch 15, 2018

P(NAME) F-604
Corrective actions for resident affected:
- An OT screen was conducted on the Residents personal wheelchair on 2/6/18.
- A physician's order was clarified on the EMR on 2/14/18.
- The In service coordinator provided 1:1 in-service to the RN on the P/P for restraints, with specific emphasis on the need for lease restrictive devices. 2/15/18.
- The CCP and C.N.A. instructions have been updated by the CCC on 2/15/18 and are reflective
of the resident's use of positioning devices.
- The Rehab Director provided in-service to the rehab dept., (2/15/18) on their responsibility for assessing
all residents' personal wheelchairs and devices. Rehab assessed all devices in house and found them to be
compliant. 2/15/18.
- The Rehab Director has developed a P&P for assessment of resident's personal wheelchair and devices and has in serviced rehab dept., on same. 2/15/18
- The restraint P&P was reviewed by the DNS and found to be accurate and comprehensive, including
lease restrictive devices. 2/15/18
Identification of residents that could be affected by the deficient practice:
- All residents that have a personal wheelchair or a personal device positioning device, or any restraint,
cold be affected by this deficient practice.
- All residents using seatbelts or any restraint will be assessed by CCC/designee to ensure that residents
have been issued the least restrictive device for their situation. Additionally, all residents with personal
wheelchairs or personal devices/positioning device will be assessed by nursing/rehab to ensure least
restrictive device is being used.
- Any deficiencies will be corrected immediately.
Systemic Measures to Prevent Recurrence:
- The in-service educator will educate all CCC's,/RN's on the restraint policy with specific emphasis on
least restrictive devices. In-Service will also include CCC's understanding that all new admissions need
rehab assessment of personal wheelchair or any personal positioning devices/restraints that the resident
may have.
- The Director of Rehab will in-service all rehab staff on the new P&P for assessing residents personal
wheelchair and devices, and will also include restraints and least restrictive devices.
- Director of rehab will in-service all rehab staff on the necessity of assessing all equipment for new
admissions, including their personal devices/restraints/positioning equipment.
Quality Assurance and Improvement with Ongoing Monitoring:
- An audit tool for least restrictive devices has been developed by the DNS.
- An audit tool to ensure rehab assessments of residents' personal wheelchair devices, positioning devices, etc., has been developed by the Rehab Director.
- The Rehab Director will conduct an audit of 100% of all residents who have their own personal wheelchair or devices every month x 3 months and quarterly thereafter when 100% compliance is achieved. Findings will be reported by the Rehab Director at the Rehab Director at the monthly QA meetings.



- The Rehab Director will conduct monthly audits x 3 months on all new admits for the month to ensure
that rehab assessments of personal wheelchair or personal positioning devices, etc., have been done.
After 3 months, or when 100% compliance is achieved, audit will continue quarterly on 50% of all new admits. Dir of Rehab will report findings at the monthly QA meeting.
- The DNS/designee will conduct monthly audits x 3 months of 100% of all residents with restraints to ensure least restrictive devices have been implemented. After 100% compliance is achieved, audits will
continue quarterly thereafter on 50% of residents with restraints. The DNS will report findings of the audit at the monthly QA meetings.
- The DNS/designee will conduct audits on 50% of all residents with restraints x 3 months to ensure 100% compliance with physician orders in place, and corroborating with CCP's and C.N.A. assignments. After
3 months, once 100% compliance is achieved, DNS/designee will conduct audits quarterly thereafter.
The DNS /designee will conduct audits quarterly thereafter. The DNS/designee will report findings at the
quarterly QA meetings.
Responsible Person: Director of Nursing
Completion date: 4/20/2018