Midway Nursing Home

Deficiency Details, Complaint Survey, October 18, 2010

PFI: 1704
Regional Office: MARO--New York City Area

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Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: December 15, 2010

The resident has the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms.

Citation date: October 18, 2010

Based on staff interviews and record review during an abbreviated survey, the facility did not ensure that a resident was free from any physical restraint imposed for purposes of discipline or convenience. This was evidenced in 1 of 4 sampled residents (Resident #1). Specifically, a resident was observed by a staff member with a sheet wrapped around the resident and tied to the back of the wheelchair. The sheet was applied by a Certified Nursing Assistant (CNA).

This resulted in no actual harm with potential for more than minimal harm that is not immediate Jeopardy.

Complaint ID# NY00083082

The finding is:

Resident # 1 is a 78 year old admitted to the facility on 4/8/08 with diagnoses including Bilateral Cerebral Atrophy, Hypertension, Senile Dementia with behavioral disturbances, Altered Mental Status and Cerebrovascular Accident. The Minimum Data Set 2.0 Assessment dated 2/18/10 documented that the resident has moderately impaired cognitive skills and impaired short and long term memory.

A Comprehensive Care Plan initiated on 6/26/09 documented that the resident is at risk for falls and injury due to a history of falls, behavior problems and Dementia/Alzheimer's. The CCP included 28 interventions including anticipating the resident's needs, a toileting schedule, bed/chair alarms, seat belt and a scoop mattress. Updates to the care plan include multiple falls and injures requiring the addition of other interventions including a merry walker. The merry walker was discontinued on 1/13/10 due to the resident's non-compliance.

The Quarterly Restraint/Siderail Evaluation dated 2/1/10 documented that the restraint order was changed from a seatbelt to a lap buddy. The seat belt was discontinued because the resident was sliding off the wheelchair under the seat belt.

The Resident Profile/CNA Assignment dated January and February 2010 documented, "Lap Buddy to be worn while in wheel chair" .

The Employee Disciplinary Record dated 3/2/10 for CNA #1 documented that "on 3/2/10 at 6:00AM the resident was tied up with a sheet on the wheel chair". The CNA's wrote a comment stating, "the night I took care of the resident he was very agitated. Without a restraint the resident can fall at any time so all shift staff use it to keep the resident from falling down because he removes the lap buddy every second".

The Quarterly Restraint/Side Rail Evaluation dated 3/3/10 documented that the restraint order was changed from a lap buddy to a three way seat belt. The lap buddy was discontinued because the resident is able to remove the lap buddy and walk away from the wheel chair. The resident is at high risk for falls and has an unsteady gait.

The Assistant Director of Nursing was interviewed on 5/28/10 at 2:00 PM. She stated she did not think the resident being tied with a sheet was abusive and that it only happened once. The ADON stated that the sheet was considered a restraint. The CNA was given a written, final warning and was in-serviced. The night-shift CNAs on the unit were also in-serviced.

The In-service Coordinator was interviewed on 6/2/10 at 4:00 PM. She stated that on 3/2/10 at 6:00 AM she was doing rounds and she saw the resident in the hallway. He did not have the lap buddy on and a sheet was wrapped around him and tied to the back of the wheel chair. She stated that she went to the Charge Nurse and asked her who was assigned to the resident. She then went directly to the assigned CNA and asked her why the resident was tied up. The CNA told the In-service Coordinator that the resident was agitated and she couldn't get her work done.

CNA #1 was interviewed on 6/3/10 at 2:00 PM. She stated that the resident had a lap buddy but he would take it off. On 3/2/10 the resident was very agitated and was trying to get on the elevator. CNA #1 stated that she was assigned to 20 residents and she couldn't take care of her of them because Resident #1 kept trying to get up. CNA #1 stated that she took a sheet and wrapped it around the resident and tied it to the back of the wheel chair.

The Licensed Practical Nurse (LPN) was interviewed on 6/3/10 at 4:30 PM. She stated that she was aware that CNA #1 wrapped the sheet around the resident and tied it to the wheel chair. She observed it during the medication pass. She stated that she did not remove the sheet because the resident was combative and she did not want him to fall. The LPN stated that the resident had been agitated the whole night and CNA #1 had to start morning care for other residents. The LPN stated that "it was not a good idea" for the CNA to tie the resident with the sheet, but the CNA needed to do her work and wanted to prevent any injuries to the resident.