**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) Resident #85 was admitted with diagnoses of non-Alzheimer's dementia and restlessness and agitation. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #85 had severely impaired cognition and required the total assistance of two staff for bed mobility and transfers. Resident #85 had no falls since the last assessment, and SRs and restraints were not in use. On 7/05/2022 at 8:59 AM, Resident #85 was observed in bed after receiving care with bilateral ½ SRs raised. There were no observations of Resident #85 being able to grab the SR. On 7/6/2022 at 9:01 AM, Resident #85 was observed receiving morning care from (Certified Nursing Assistant) CNA #2 and CNA #6. Bilateral ½ SRs were raised at the start of care. CNA #2 and CNA #6 both lowered a ½ SR and washed Resident #85's face and body. Both CNAs positioned Resident #85 in bed and raised the bilateral ½ SRs after care was completed. Resident #85's body was stiff and unable to move without assistance. One of the CNAs prompted Resident #85 to grab onto the ½ siderail, and Resident #85 was unable to follow the command. The Comprehensive Care Plan (CCP) related to fall potential initiated 7/23/2020 and last revised 7/2/2022 documented Resident #85 was at risk for falls due to the behavior of trying to get out of bed unassisted, impaired cognition, impaired judgement, and poor safety awareness. The interventions included bed alarm and floor mats for safety. The CCP related to skin integrity initiated 7/23/2020 and last revised 10/24/2021 documented Resident #85 was provided with bilateral ½ SR to assist with positioning and comfort. The Physician's Order (PO) initiated 7/23/2020 and last renewed 6/15/2022, documented orders for bilateral ½ SRs. There was no indication of medical necessity in the order. The SR assessment dated [DATE] documented Resident #85 was able to follow instructions, unable to retain information, unable to physically release the SRs, had a history of SR use, and did not attempt to get out of bed. Resident #85's designated representative requested SR use and ½ upper SRs were indicated to assist in bed mobility. The Briggs Fall Risk assessment dated [DATE] documented Resident #85 scored a 10, indicating Resident #85 was at high risk for falls. There was no documented evidence other alternatives were tried prior to the use of bilateral ½ SRs. There was no documented evidence a SR safety assessment was completed prior to the application of bilateral ½ SRs. There was no documented evidence Resident #85 was observed using the ½ SR as an enabler. The bilateral ½ SRs were not identified as a restraint, and there was no restraint CCP in place. During an interview conducted on 7/05/2022 at 8:59 AM, CNA #2 stated Resident #85 was totally dependent on staff for turning and positioning and cannot move side to side in bed without assistance. Bilateral floor mats are in place and the bed is kept in the lowest position because Resident #85 attempts to get up without assistance. CNA #2 stated Resident #85 has attempted to get out of bed by grabbing the SR. During an interview conducted during an observation of care on 7/6/2022 at 9:01 AM, CNA #6 and CNA #2 were interviewed and both stated Resident #85 can move their arms, cannot move in bed by themselves, and cannot assist in their own care. On 7/1/2022 at 10:15 AM, Licensed Practical Nurse (LPN) #3 was interviewed and stated Resident #85 could not release the SRs and the SRs were used for Resident #85 because the resident has a behavior of moving up and down in the bed. Along with floor mats, it is a safety feature. 3.) Resident #95 was admitted with diagnoses of Unspecified Dementia with Behavioral Disturbance and hemiplegia following cerebral infarction affecting the left non-dominant side. On 7/5/2022 at 5:56 PM, Resident #95 was observed in bed with the bilateral ½ SRs raised. The Certified Nursing Assistant (CNA #7) called Resident #95 by name and prompted them to hold onto the ½ SR. Resident #95 did not respond or follow the command. The Minimum Data Set (MDS) dated [DATE] documented Resident #95 required extensive assistance of 1 person for bed mobility and extensive assistance of 2 people to transfer. An active Physician's Order (PO) initiated 10/23/2021 documented orders for Resident #95 to have bilateral ½ SRs. There was no indication of medical necessity in the order. A SR assessment dated [DATE] documented Resident #95 used the SR to enhance bed mobility, did not attempt to get out of bed unassisted, did not use the SR to adjust his or her position in bed, and was not able to physically release the SR. The Interdisciplinary Team (IDT) documented a recommendation for Resident #95 to have ½ upper SR to assist in bed mobility and transfers. The Comprehensive Care Plan (CCP) related to Activities of Daily Living (ADL) initiated 10/25/2021 and last revised 6/28/2022 documented Resident #95 was severely cognitively impaired, non-ambulatory, had decreased mobility and required extensive assistance of 1 person and SR for bed mobility. The CCP related to fall potential, initiated 10/25/2021 and last revised 6/28/2022, documented Resident #95 had impaired cognition and impaired vision. Bilateral ½ SRs were used as enablers with bed positioning. A Physical Therapy (PT) Evaluation dated 10/25/2021 documented Resident #95 required maximum assistance for bed mobility. Restorative therapy was recommended, and a goal was set for the resident to be able to perform bed mobility with moderate assistance with use of SRs for initiation / termination of tasks, for proper sequencing and for task segmentation in order to get in/out of bed, prepare for transfers and participate in edge of bed activities. The PT Discharge summary dated [DATE] documented Resident #95 required maximum assistance for bed mobility and did not meet the therapy goals. The Briggs Fall Risk assessment dated [DATE] documented Resident #95 scored a 12, indicating high risk for falls. There were no observations of Resident #95 using the ½ SR as an enabler. There was no documented evidence other devices were used as enablers or a SR safety assessment was completed prior to the implementation of bilateral ½ SR. The bilateral ½ SR were not identified as a restraint. On 7/5/2022 at 1:04 PM and 6:12 PM, CNA #7 was interviewed and stated Resident #95 could not participate in care or follow instructions. Resident #95's left hand was weak, but Resident #95 can hold onto the SR with the right hand if it is placed there. CNA #7 stated Resident #95 has not attempted to get out of bed. The SRs stop the resident from falling on the floor during care. Resident #95 cannot roll by themselves, but when CNA #7 turns the resident, the resident's body moves and can tip over. CNA #7 stated the resident requires two people to assist them with bed mobility and turning/positioning. SRs can be considered a restraint but not for this resident. During an interview on 7/5/2022 at 3:03 PM, Licensed Practical Nurse (LPN) #4 stated the SRs are used because Resident #95 moves while they are in bed, at times, and staff reported Resident #95 had their leg hanging off the side of the bed. LPN #4 also stated the resident's family wanted side rails in place. On 7/5/2022 at 01:13 PM, the Nurse Educator was interviewed and stated SR were used to assist residents with positioning while in bed. SR were considered a restraint if used for residents who were unable to use the SR unassisted. On 7/8/2022 at 11:38 AM, Physician #1 was interviewed and stated SRs were used for mobility to transition in bed and were not used for resident safety. SRs were considered a restraint if SRs were used without proper indications. During an interview on 7/6/2022 at 3:23 PM, the Director of Rehab stated rehab only assesses residents for bed mobility and transfers, not SR use. The SR assessment is completed by nursing. On 7/6/2022 at 10:53 AM, the Director of Nursing (DON) was interviewed and stated residents were assessed for their ability to move in bed and if they required SRs. The SRs are raised during care, if necessary, otherwise, the SRs are removed. Resident information is reviewed prior to admission to determine the type of bed a resident requires. The Maintenance Department was responsible for measuring the beds and SRs. The nurse assesses and determines whether Maintenance needs to address issues with a resident's bed. On 7/8/2022 at 11:43 am, the Medical Director was interviewed and stated the IDT asked them to make a list of residents who are alert & oriented and who may have a diagnosis that may benefit from side rails such as Multiple Sclerosis. The Medical Director was asked to review cases on units 1, 2, and 4. Unit 3 has residents with psychiatric diagnoses so that unit was not reviewed. The Medical Director further stated they have read the F-tag and agree with it and have reviewed the plan of correction with the Administrator. Immediate Jeopardy (IJ) was identified and declared. The facility Administrator and Director of Nursing were notified on 7/6/2022 at 6:00 PM. The facility submitted a removal plan that was reviewed and accepted by the NYSDOH on 7/8/2022 at 4:00 PM. On 7/8/2022 at 4:00 PM, the survey team declared the IJ was removed based on the following corrective actions taken by the facility: - For Resident #95 and Resident #42, SR assessments were completed, and the Physician discontinued SRs for both residents. Both residents were observed with no SR in place on 7/07/2022 and 7/08/2022. - For Resident #85, a SR assessment was done, and the IDT determined there was a medical justification for bilateral 1/2 SR use. The MDS was reviewed for accuracy. This was completed by 7/08/2022. - All residents with POs for SR were assessed for clinical justification and appropriateness of SR use by 7/8/2022. - The maintenance personnel will remove the SRs for all residents who did not require them based on the assessment by the IDT by 7/11/2022. As of 7/8/2022, 96% of SRs were removed with 4% (3) still pending. - Policy for 'SR Utilization' was reviewed and revised on 7/6/2022. The revised policy ensured consistency between the SR assessment and MDS. PT was included in SR assessments, and the assessment will include the residents' ability to release the SR to determine if it is a restraint. - The Policy for 'Use of Restraints' was reviewed 7/6/2022 to ensure that a mechanism for release of the SR and/or restraint was in place. The opportunity for motion and exercise is provided for a period of no less than ten (10) minutes during each two (2) hours in which restraints are employed. - In-service lesson plan and sign-in sheets were reviewed 7/08/2022 and education was provided to 89% of staff (department heads, Administration, Nursing, MDS Department, Dietary, Housekeeping/Maintenance, Recreation, Social Work, Rehabilitation Department) re: restraints and SR identification, indication, and implementation of policy. - Interviews were conducted with the following staff who were in-serviced on restraints and SRs: 4 RNs, 2 LPNs, 13 CNAs, 1 MD, 2 Social Workers, 1 Recreation staff member, and the Administrator. All staff were in-serviced and knowledgeable on Restraints and SR. Based on observation, interview and record review conducted on 7/8/2022, the facility fully implemented the IJ Removal Plan, and the IJ was removed as of 7/8/2022 at 4:00 PM. 415.4(a)(2-7) Based on observation, record review and interviews conducted during the extended recertification and abbreviated (NY00290309) survey from 6/27/2022 through 7/12/2022, the facility did not ensure that each resident remained free from physical restraints not required to treat the resident's medical symptoms. This was evident for 14 of 14 residents reviewed for Physical Restraints (Resident #s 85, 95, 42, 190, 23, 69, 76, 121, 63, 136, 71, 12, 40 and 31) out of a sample of 43 residents. Specifically, Resident #42 had severely impaired cognition and required extensive assist of one person for bed mobility and transfers. Resident #42 had orders for bilateral ½ side rails SR, and the SR were not identified as a restraint. Resident #42 sustained an injury to the right eyelid after hitting their head on a ½ SR. There was no medical justification, SR safety assessment prior to SR use, restraint care plan, or evidence of alternatives attempted before using the bilateral ½ SR. Resident #s 85, 95, 190, 23, 69, 76, 121, 63, 136, 71, 12, 40, and 31 had severely impaired cognition and required extensive to total assistance of two persons for bed mobility and transfers. The affected residents had orders for bilateral ½ SR, and the SR were not identified as a restraint per the SR assessment. There was no medical justification, SR safety assessment prior to SR use, restraint care plan, or evidence of alternatives attempted before using the bilateral ½ SR. This resulted in Immediate Jeopardy (IJ) with the likelihood for serious, injury, serious harm, serious impairment, or death to all residents using SR or other devices that were potential restraints. IJ was identified and declared. IJ began on 07/05/2022 and was called on 07/05/2022 at 8:59AM. The facility submitted an IJ removal plan on 07/08/2022. IJ was removed on 07/08/2022 at 4:00 PM. The findings include but are not limited to: The facility policy titled Use of Restraints last reviewed 9/2021 documented: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. The order shall include the following: a. the specific reason for the restraint (as it relates to the resident's medical symptom); b. how the restraint will be used to benefit the resident's medical symptom, and c. the type of restraint, and period of time for the use of the restraint. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s). References: related documents: risk-benefit acknowledgement form (MP5540); Physical Restraints - record of informed consent. The policy titled Proper Use of SR last reviewed 12/2021 documented SR are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). SR are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using SR. When used for mobility or transfer, an assessment will include a review of the resident's: bed mobility, ability to change positions, transfer to and from bed or chair, and to stand and toilet; risk of entrapment from the use of SR, and that the bed's dimensions are appropriate for the resident's size and weight. When SR usage is appropriate, the facility will assess the space between the mattress and SR to reduce the risk for entrapment. 1.) Resident #42 was diagnosed with dementia and hip fracture. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #42 was severely cognitively impaired and required extensive assistance of two people for bed mobility and transfers. On 7/06/2022 at 7:40 AM, Resident #42 was observed sleeping in bed with the right ½ SR in the raised position. No staff were observed in the room. On 7/06/2022 at 7:57 AM, Resident #42 was observed awake in bed with the right ½ SR in the raised position. The Physician's Order (PO) initiated 3/6/2018 and last renewed 6/29/2022 documented orders for Resident #42 to have bilateral ½ SRs. There was no indication of medical necessity in the order. A Facility Accident/Incident Investigation dated 9/13/2020 documented Resident #42 turned to their right side while receiving care from the Certified Nursing Assistant (CNA) and hit their eye on the SR sustaining a scratch to the right eye lid. The corrective action was to encourage the resident to turn slowly. The Fall Risk assessment dated [DATE] documented Resident #42 did not have any falls and scored a 7, indicating they were not at high risk for falls. The SR assessment dated [DATE] documented Resident #42 was able to follow instructions, not able to retain information, not physically able to release the SR, used the SRs to enhance mobility, and attempted to get out of bed by themselves. The assessment did not contain a medical justification for the use of SRs. There was no documented evidence other devices were used as enablers or a SR safety assessment was completed prior to the use of the ½ SRs. The bilateral ½ SRs were not identified as a restraint. On 7/5/2022 at 1:26 PM, Licensed Practical Nurse (LPN) #1 was interviewed and stated SRs can be used when the resident can hold onto the SRs to help turn themselves. SRs were considered a restraint if the resident was unable to use the SRs independently. The Registered Nurse Manager (RNM) assesses the residents to determine whether SR use is appropriate. During an interview on 7/5/2022 at 1:13 PM, RNM #1 stated Resident #42 needed bilateral 1/2 SR to prevent falls and assist with bed mobility. The RNM obtains consent from the resident or resident's family for SR use. If the resident is cognitively impaired and there is no family, an Interdisciplinary Team (IDT) meeting is held, and the Physician decides if SRs are necessary. A 3-day assessment is done for new admissions, readmissions, and residents with significant changes to determine if SRs are necessary. The RNMs write the PO, a progress note, and update the resident's care plan. Bilateral ½ SRs are not considered a restraint.