Failure to Identify Bed Placement as Restraint
Penalty
Summary
The facility failed to identify the placement of beds against the wall as a restraint for three residents, which is a violation of their right to be free from physical restraints not required to treat medical symptoms. The facility's policy defines physical restraints as any device that restricts freedom of movement and cannot be easily removed by the resident. Observations revealed that the beds of Residents R247, R248, and R249 were placed against the wall, which was not documented in their care plans or assessments as a safety measure or preference. Resident R247, diagnosed with Alzheimer's disease and at high risk for falls, had no care plan addressing the bed placement. Resident R248, with intact cognition and a history of respiratory failure and falls, also lacked documentation for the bed's position. Resident R249, with hypertensive urgency and intact cognition, confirmed that the bed's placement was not their preference. Interviews with staff, including an LPN and the Director of Nursing, confirmed the bed placements, indicating a failure to adhere to the facility's restraint policy.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Residents R247, R248, R249 were interviewed by DON and NHA to obtain preferences for the placement of the beds and adjusted as needed. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Residents with beds near the wall were interviewed by DON and NHA regarding their preferences and beds were adjusted and care plan updated to reflect their request. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five residents to ensure that bed placement preferences are in place and the care plan is being followed. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.