Summers Healthcare, Llc

Penalty

Inspection fine: $13,627

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

An Immediate Jeopardy (IJ) situation was identified due to the facility's failure to provide a safe environment for Resident #1, who was found with her left arm caught in a bed rail that had fallen on it. The incident was documented on 01/03/24, and the resident was subsequently transferred to the ER on 01/04/24, where she was diagnosed with a closed fracture of the left distal humerus. Despite the injury, the resident was observed on 01/17/24 with two upper bed rails raised, indicating that no new interventions had been put in place to prevent further injury. The Director of Nursing (DON) acknowledged on 01/18/24 that no physician's orders or bed rail risk assessments had been completed for Resident #1. Additionally, there was no documentation that the risks and benefits of using bed rails had been discussed with the resident's representative, nor was there any signed consent obtained before the bed rails were put in use or upon the resident's return from the hospital. This lack of proper assessment and documentation contributed to the unsafe environment that led to the resident's injury. The facility's failure to identify and eliminate a known and foreseeable accident hazard was evident in the case of Resident #1, who had severe cognitive impairment, limited movement, and was dependent on others for all activities of daily living (ADLs). The absence of a bed rail risk assessment and the continued use of bed rails without proper authorization and safety measures directly led to the resident's injury, highlighting a significant deficiency in the facility's safety protocols and resident care practices.

Removal Plan

• All bedrails in the facility were lowered pending Pre-restraining assessment, restraint: side rail utilization assessment, consent from resident/family member for physical restraint and physicians order for the use of bedrails.
• Resident #1's bedrails were lowered, her bed was lowered to the lowest position and pillows were placed to maintain position for her protection.
• All residents or their families were educated on the pros and cons of bedrail restraints.
• Pre-restraining assessments were completed on all residents.
• Side rail utilization assessments were completed on five residents requesting bedrails.
• Consents were obtained verbally from Resident #1's guardian, unnamed resident #2's POA, and Resident #3, and consent forms were mailed to them.
• Physician's orders were obtained for the five residents that requested bedrails be utilized while in bed.
• Care plans have been updated for the residents requesting bedrails.
• The five residents that have requested bedrails will be reassessed and consents will be updated.
• Residents that have requested some type of bedrail will be visualized for safety and positioning every two hours and as needed while in bed when bedrail is being utilized.
• All bedrails in the facility that are not being used have been zip tied to prevent use when not authorized by staff and visitors without proper assessments, consents and orders.
• Staff have been educated on the facility policy for restraints: pre-restraining assessment, side rail utilization assessment, consent for side rail and physicians order for side rails.
• Staff were educated on making sure residents are safe and moved from faulty bed then reporting to maintenance log.
• Staff were in-serviced on procedure for reporting faulty bed to maintenance using identifying bed number along with room number and problem that has been identified to maintenance in the maintenance logbook.
• All beds were reassessed for proper working order.
• All beds will be assessed for proper working order utilizing a tracking log.
• The maintenance supervisor or designee will monitor the maintenance log for any beds that are not working properly.
• The Director of nurses or designee will assess all residents upon admission for restraints and consents will be obtained upon admission per facility restraint policy.
• The QAPI committee will review all new assessments and consents for new admissions.
• Care plans will be updated on admission.
• The QAPI committee will review all care plans for residents that have requested bedrails.
• The Maintenance Supervisor will address any bed or equipment issues with the QAPI committee.
• The Maintenance Supervisor will present bed tracking log to the QAPI committee.

Penalty

Inspection fine: $13,627

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to have a qualified activity director for 19 of 19 residents. On 01/18/24 at 1:10 p.m., the Director of Nursing (DON) confirmed that the facility did not have a certified activity director. Instead, a Certified Medication Aide (CMA) and other staff members were handling the activities. The DON confirmed that neither the CMA nor any other staff members were certified activity directors. Later, at 3:56 p.m., the Administrator reported that the last certified activity director left the facility on 07/31/23.

Penalty

Inspection fine: $13,627

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement interventions for reducing or discontinuing the use of bed rails and provide ongoing monitoring and evaluation for three residents with bed rails in use. Resident #1, who had diagnoses including gastrostomy, tracheostomy, and ventilator dependence, was observed with two upper bed rails raised. Resident #3, with similar diagnoses, was observed with four bed rails raised. Resident #4, also with gastrostomy and tracheostomy, was observed with two upper bed rails raised. There were no documented interventions in the care plans of these residents to reduce or discontinue the use of bed rails, nor was there any documentation of ongoing monitoring and evaluation of bed rail use. The Director of Nursing confirmed that no monitoring or evaluations had been documented for these residents.

Penalty

Inspection fine: $13,627

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to properly assess the need and safety of bed rail use for three residents, discuss the risks and benefits with the residents or their representatives, obtain informed consent, and secure a physician's order for the use of bed rails. Specifically, three residents with diagnoses including gastrostomy, tracheostomy, and ventilator dependency were observed with bed rails raised, but their clinical records lacked documentation of the reasons for bed rail use, the associated risks and benefits, informed consent, and physician's orders. The facility's policy mandates these steps, but they were not followed in these cases. The Director of Nursing (DON) confirmed that bed rails should only be used with a physician's order and resident or family consent. However, upon review, the DON acknowledged that there was no documentation in the clinical records of the three residents regarding the necessity, risks, benefits, informed consent, or physician's orders for the bed rails. This oversight indicates a failure to adhere to the facility's established policy on bed rail use, potentially compromising resident safety and compliance with regulatory standards.