Valley Health Services Inc

Based on observations, record reviews, and interviews with staff conducted during the standard survey, it was determined for 3 of 9 residents reviewed for physical restraints (Residents #4, 5, and 19), the facility did not ensure the resident's right to be free from physical restraints not required to treat the residents' medical symptoms. Specifically, there was no evidence the facility reassessed the tray restraint for safety and/or restraint reduction/elimination for Residents #4 and 19. Resident #5 did not have a care plan developed for the hand mitt restraints on both hands; and Resident #19 had a restraint without a physician's order. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #4 was admitted to the facility with diagnoses of cerebellar (brain) degeneration with dementia, agitation, chronic adjustment disorder, required a feeding tube and had contractions of all 4 extremities.

Current physician orders, dated June 23, 2010, specified for the resident to have a positioning chair with lap tray elevated, when out of bed, with Dycem (a thin non-slip mat), to be released every 2 hours and as needed.

An Incident Report dated July 6, 2010 at 7:25 PM documented the resident was found on the floor in her room, with her back on the foot part of the chair. Her right foot was caught under the bed behind the wheel, and her left arm was caught in the chair table. The resident received small abrasions on both knees and right lower shin. To prevent recurrence, the report specified "staff informed that after supper, this resident is to be one of the first in bed."

The quarterly Minimum Data Set (MDS) assessment, dated July 16, 2010, documented the resident had short and long term memory deficits, with severely impaired cognitive skills. The resident was totally dependent on staff for all activities of daily living (ADLs) and was incontinent of bowel and bladder.

The resident's Restraint Review, last updated on July 26, 2010, recommended a positioning chair with a raised tray table, due to the resident's involuntary movements and poor trunk control.

The current comprehensive care plan (CCP), updated July 27, 2010, documented due to the resident's diagnosis, she had had involuntary movements and poor trunk control. Interventions included a positioning chair with tray table and padded leg rests, and staff needed to place a cushion on the footrest of the chair to prevent injury.

The certified nurse aide (CNA), assigned to care for Resident #4, was interviewed on August 18, 2010 at 12:20 PM. The CNA stated she has taken care of the resident for the past 3-4 years. The CNA said staff kept the tray table up to prevent the resident from falling out of the chair. When the resident was fed, staff removed the tray table. The CNA stated the resident slid down in the chair; however she did not think the resident ever slid out of the chair.

The licensed practical nurse (LPN) (who worked the 3 PM to 11 PM shift on July 6, 2010) was interviewed on August 18, 2010 at 3:10 PM. When asked how he found the resident on the day of the incident, the LPN stated the resident slid down in the chair, her left arm was caught on the tray table, her head was under the tray table, and her legs were under the bed.

The registered nurse (RN) clinical co-ordinator was interviewed on August 18, 2010 at 3:20 PM. The RN said there had been no re-evaluation of the resident's restraint to see if it was the safest and/or the least restrictive restraint.

In summary, after the resident slid under the lap tray, the facility did not ensure the resident's restraint (a lap tray) was evaluated for safety and for being the least restrictive device.

2) Resident #5 had diagnoses including seizure disorder, quadriplegia, traumatic brain injury (TBI), dementia, and aphasia (speech difficulties).

The Minimum Data Set (MDS) assessment dated June 13, 2010 documented the resident had severe cognitive impairment, was totally dependent for all activities of daily living (ADLs), and utilized a trunk restraint.

The comprehensive care plan (CCP), last updated on June 21, 2010, documented the resident wore hand mitts (padded hand coverings) while in bed, that he was able to remove.

The resident's Restraint Review, last updated on June 21, 2010, documented the resident used an over-the-shoulder harness while in his wheelchair, due to his unpredictable spastic movements from his TBI. The review did not document the use of the resident's hand mitts.

Physician's orders, dated July 13, 2010, documented the resident used an over-the-shoulder harness while in his wheelchair, a soft neck cervical collar to be worn when in the wheelchair if tolerated, and hand mitts to be used while in bed.

The surveyor observed the resident on August 17, 2010 at 5:35 PM and August 18, 2010 at 2:15 PM, to be lying in bed in his room, with large, padded mitts covering both his hands.

The unit registered nurse (RN) Nursing Care Coordinator was not available for interview.

When the Director of Nursing (DON) was interviewed on August 18, 2010 at 2:30 PM, she said the resident wore hand mitts while in bed, because he attempted to pull out his feeding tube. She stated the resident did not understand the reason for the hand mitts, and was unable to communicate due to his aphasia. The DON said the resident's hand mitts were not care planned as a restraint, as he was able to "work them" off his hands, while he was in bed.

In summary, the facility did not ensure the resident's hand mitts were care planned as restraint, when they limited access to parts of his own body.

3) Resident #19 was admitted with diagnoses of status post frontal lobotomy (brain surgery), seizures, and rheumatoid arthritis.

According to the Bed Mobility Assessment dated February 21, 2010, the resident required 2 people and a mechanical lift for transfers and bed mobility, and specified the resident exhibited minimal voluntary movement.

The quarterly Minimum Data Set (MDS) assessment, dated May 1, 2010, documented the resident was severely cognitively impaired. She was non-ambulatory, was totally dependent on staff for all activities of daily living (ADLs), was incontinent of bowel and bladder, and had limited range of motion in all extremities.

The resident's most recent physician orders dated June 11, 2010 contained no order for a physical restraint.

The current Restraint Review dated August 10, 2010 documented a restraint (a positioning chair with tray table) was used because of poor trunk control, and the team recommended continuing the use of the tray table.

On August 18, 2010 at 12:10 PM, the resident was observed sitting in the dining room in a positioning chair with the tray table up. When lunch was served at 12:30 PM, the tray was removed while the resident was fed by staff. At 1:50 PM, the resident was observed sitting quietly in her room in her positioning chair with the tray table up.

During an interview on August 18, 2010 at 3:20 PM, the registered nurse (RN) clinical co-ordinator was asked about the resident's restraint. The RN said the resident did not move or slide in the chair, and had not been re-evaluated for a less restrictive restraint or elimination of the restraint. When asked about the lack of a physician's order for the restraint, the RN reviewed the medical record and could not find a current order. The RN stated a page of orders was missing from the resident's record and she would get an order for the restraint.

In summary, the facility:
- did not ensure the resident's restraint was evaluated for a less restrictive restraint or for elimination;
- did not ensure there was a current physician's order for the resident's restraint.

10 NYCRR 415.4 (a)(2-7)

Based on record reviews and staff interviews conducted during the standard survey, the facility did not ensure a thorough investigation of accidents/incidents was completed for 1 of 24 residents in the survey sample (Resident #4). Specifically, the facility did not conduct a thorough investigation to determine the root cause and prevent recurrence of Resident #4's slide from of a chair with its tray table attached. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #4 had diagnoses of cerebellar (brain) degeneration with dementia, agitation, chronic adjustment disorder, and contractions of all 4 extremities.

Current physician orders, dated June 23, 2010, specified a positioning chair, with Dycem (a thin non-slip mat), and elevated lap tray when the resident was out of bed, with its release every 2 hours and as needed.

The registered nurse (RN) progress note, dated July 6, 2010 at 7:25 PM, documented the resident was "observed on the floor next to the bed, resident slid out of the wheelchair, right ankle under bed frame with indentations noted to right ankle, abraisions on her knees, no bleeding, resident alert, no crying out in pain, transferred back into bed."

An Incident Report, dated July 6, 2010 at 7:25 PM, documented the resident was found on the floor in her room, with her back on the foot part of the chair. The resident's right foot was caught under the bed, behind the bed's wheel; and her left arm was caught in the chair table. The resident received small abrasions on both knees and her right lower shin. The "action taken" to prevent recurrence was: "staff informed that after supper, this resident is to be one of the first in bed." There was no documented investigation how the resident was able to slide under the tray table, and no investigation to determine if her care plan was followed.

The resident's quarterly Minimum Data Set (MDS) assessment, dated July 16, 2010, documented the resident was severely cognitively impaired, was totally dependent on staff for all activities of daily living (ADLs), and was incontinent of bowel and bladder.

A Restraint Review, last updated on July 26, 2010, and the current comprehensive care plan (CCP), updated on July 27, 2010, documented a positioning chair with tray table up due to the resident's involuntary movements and poor trunk control.

During an interview with the licensed practical nurse (LPN) on August 18, 2010 at 12:40 PM, the LPN stated the resident thrashed about and slid down in her chair. She stated Dycem was placed under the resident to prevent her sliding from the seat cushion. When asked whether the resident had a history of sliding out of the chair, the LPN said the resident slid out "a couple of months ago."

On August 18, 2010 at 1:20 PM, an interview was conducted with the Director of Nurses (DON). The DON was asked for the investigation of the incident which occurred July 6, 2010. The DON said staff filled out an incident report; she stated there was no further investigation into the incident, as the resident slid under the table with no major injury.

In summary, the facility did not conduct a thorough investigation of the incident:
- there was no investigation to determine the root cause of the incident to see how the resident was able to slide under the tray table;
- there was no investigation to determine if staff properly positioned the resident and if the tray table was properly positioned;
- there was no investigation to determine if the Dycem mat was in the chair as ordered;
- the resident's care plan did not include use of the physician-ordered Dycem mat.

10 NYCRR 415.4 (b)(1)(ii)