**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of facility documentation, medical record review, observation, and interview, the facility failed to recognize and use the least restrictive interventions or restraint device for the least amount of time and failed to attempt a reduction to a least restrictive device or eliminate the restraint devices during the 30-day assessments. The facility's failure to recognize and use the least restrictive interventions or restraint device for the least amount of time and failure to attempt a reduction to a least restrictive device or eliminate the restraint devices during the 30-day assessments resulted in 4 residents of 29 residents (Residents #9, #13, #18, and #21) being placed in restraints that were not the least restrictive for an extended amount of time. The findings include: Review of the facility's undated policy titled, POLICY AND PROCEDURE FOR RESTRAINTS AND SAFETY DEVICES, showed .Facility will use the least restrictive safety device or restraint to ensure safety of the resident .Interdisciplinary team will meet once a week to .Decrease safety devices and restraints if no incident in last 30 days .will ensure that the least restrictive safety device or restraint is used for the least amount of time to ensure resident safety . Review of the medical record showed Resident #13 was admitted to the facility on [DATE] with diagnoses including Dementia, Bipolar Disorder, and Anxiety Disorder. Resident #13 was discharged to another facility on [DATE]. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE], showed Resident #13's Brief Interview of Mental Status (BIMS) score was 0, indicating the resident had severe cognitive impairment and the resident required assistance of one or more persons with activities of daily living (ADL's). Review of a physician's order for Resident #13 dated [DATE] (2 days after admission), showed .BED IN LOWEST POSITION WITH VEST RESTRAINT [vest with tie-ends for bed or chair application/most restrictive device] .for 30 days . Review of the initial restraint review form for Resident #13 dated [DATE], showed .Type of device: BED IN LOWEST POSITION WITH VEST RESTRAINT. CHECK Q [every] 30 MINUTES, AND RELEASE Q2 HOURS FOR TOILETING AND EXERCISE PERIODS .NEW ORDER FOR RESTRAINT .RESIDENT HAS HAD CONFUSION AND RECENT DIAGNOSIS OF PNA [Pneumonia] AND STARTED ABX [antibiotic] RESIDENT HAS HAD MULTIPLE ATTEMPTS OUT OF BED UNSAFELY AND IS WAKING UP ROOMMATE RESIDENT IS STANDING OVER ROOMMATE AND IS TRYING TO CLIMB INTO THEIR BED .POOR TRUNK CONTROL .UNSTEADY GAIT AND BALANCE, RESIDENT LEANS TO RIGHT SIDE WHILE AMBULATING AND KEEPS HEAD IN DOWNWARD POSITION .IMPULSIVENESS AND DECREASED SAFETY AWARENESS DUE TO SENIL [senile] DEGENERATION OF BRAIN, DEMENTIA .RESIDENT NOT AWARE OF SURROUNDINGS, OTHER RESIDENTS, OR SITUATIONS, ALERT TO SELF ONLY .GENERALIZED WEAKNESS NOTED TO BILATERAL LOWER EXTREMITIES .REEVALUATE IN 30 DAYS OR PRN [as needed] . Documentation on the initial restraint review showed the Director of Nursing (DON), Quality Assurance (QA) Registered Nurse (RN), and the Director of Rehabilitation (DOR) attended the meeting. Review of the final 30 day restraint review form for Resident #13 dated [DATE], [26 weeks after the initial restraint] showed .Type of device: SR [self release] BELT IN CHAIR VEST IN BED .attempts made at reduction UNSUCCESSFUL [no attempts listed on form, see progress note below] alternatives attempted .Frequent repositioning Offered fluids/snacks Diversional activities Ambulation Toileting .Team recommendations; OOB [out of bed] IN ROCK-N- GO [rocking wheelchair] W [with]/SR BELT, OBSERVE Q 30 MINUTES RELEASE Q 2 HOURS FOR TOILETING AND EXERCISE PERIODS .BED IN LOWEST POSITION W/VEST RESTRAINT, OBSERVE Q 30 MINUTES, RELEASE Q 2 HOUR FOR TOILETING AND EXERCISE PERIODS . Review of a progress note for Resident #13 dated [DATE], showed .RESIDENT OBSERVED UNSAFELY EXITING ROCK-N-GO CHAIR UNABLE TO REDIRECT RESIDENT DESPITE MULTIPLE ATTEMPTS LAID RESIDENT IN BED FOR REST PERIOD WITH NO SUCCESS NEW ORDERS RECEIVED AND NOTED FOR OOB IN ROCK N GO W/SR BELT OBSERVE Q 30 MINUTES RELEASE Q2 HOUR .BED IN LOWEST POSITION W/VEST RESTRAINT OBSERVE Q 30 MINUTES RELEASE Q2 HOUR . Review of a Restraints MEETING MINUTES form dated [DATE], showed .[Resident #13] cognition continues to decline .noted with less physical activity .resident has shown no signs of attempting to self transfer since last assessment Resident is sleeping throughout the night with no attempts to exit the bed .attempt restraint reduction at this time .MD [Medical Director] notified and agrees . Review of a physician's order for Resident #13 showed the resident's restraints were discontinued on [DATE] with no new orders for restraints noted showing Resident #13 went from the most restrictive restraint device to no restraints used. (The vest restraint was continued on Resident #13 from [DATE] (2 days after the resident's admission) through [DATE] without a reduction in the restraint). Review of the medical record showed Resident #21 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Dementia, and Abnormalities of Gait. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] showed Resident #21's Brief Interview of Mental Status (BIMS) score was 6, indicating the resident had severe cognitive impairment and the resident required assistance of one or more persons with ADL's. Review of a physician's order for Resident #21 dated [DATE], showed .OOB in lowrider [wheelchair that sits low] with pelvic restraint [restraint for chair use/most restrictive chair restraint] .bed in lowest position with vest restraint . Review of the initial restraint review form for Resident #21 dated [DATE], showed .OOB in low rider [wheelchair that sits low] with pelvic restraint bed in lowest position with vest restraint .new restraint .comments .Resident continues to slide down in chair despite dycem [nonslip material] being placed in chair, resident leans over right side over chair multiple attempts made to reposition in chair to remain in upright position .at night resident unsafely ambulates in room pulling covers off roommate and attempting to climb into roommates bed stating this is her house .Team recommendations: OOB in lowrider with pelvic restraint, bed in lowest position with vest restraint .dycem in chair between cushion and chair .resident has poor trunk control slides to edge of chair .dementia with agitation and behavioral disturbance anxiety disorder .generalized muscle weakness . Documentation of the initial restraint review showed the meeting was attended by the DON, ADON, QA RN, and the DOR. Review of the most recent 30 day restraint review form for Resident #21 dated [DATE] [12 weeks after initial restraint], showed .Type of device OOB in lowrider with self releasing clip belt .attempts made at reduction .self release clip belt was discontinued however was unsuccessful resident noted sliding down in chair due to no trunk control or upper body strength Resident thinks she can still self transfer however she has no strength or safety awareness .Team recommendations OOB in low rider with self releasing clip belt observe q [every] 30 minutes release q2 hours .resident has poor trunk control slides to edge of chair difficulty in walking unsteadiness on feet lack of coordination unable to ambulate safely .dementia with agitation and behavioral disturbance, .generalized muscle weakness receives hospice services . Review of this meeting showed it was attended by the DON, QA RN, and the DOR. During an observation on [DATE] at 8:00 AM, in the Resident 21's room, showed Resident #21 seated in a lowrider with SR belt in place. Resident #21was unable to remove the belt upon request. Review of the medical record showed Resident #18 was admitted to the facility on [DATE] with diagnoses including Dementia, Abnormalities of Gait, and Dissociative Fugue [temporary state of memory loss]. Review of the quarterly MDS assessment dated [DATE], showed Resident #18's BIMS score was 0 indicating the resident had severe cognitive impairment and required assistance of one or more persons with ADL's. Review of a physician's order for Resident #18 dated [DATE], showed .OOB in lowrider with self releasing clip belt . Review of the initial restraint review form for Resident #18 dated [DATE], showed .Type of device; lowrider with self releasing clip belt .new order; Resident continues with fast shuffle downward gaze .attempts made for reduction .Multiple attempts made for rest periods with resident however they were unsuccessful resident is tiring self out and is starting to stumble into things and due to downward gaze is running into other residents Resident in floor under tables and beds .Spoke with residents sister states that resident worked in a factory on an assembly line for over 20 years and that she walked/jogged 5 miles everyday, she was very active and always tried to fix things .Team recommendations: lowrider with self releasing clip belt observe q 30 minutes release q2 hours for toileting and exercise periods for decreased safety awareness . Review of the meeting documentation showed it was attended by the DON, ADON, QA RN, and the DOR. Review of a physician's order for Resident #18 dated [DATE] showed .OOB in lowrider with self release clip belt .bed in lowest position with vest restraint . Review of the last 30 day restraint review form for Resident #18 dated [DATE] [32 weeks after initial restraint], showed .Type of device: OOB in lowrider with self releasing clip belt, vest in bed .attempts made at reduction .SR belt and vest restraint was d/c'd [discontinued] however resident noted walking in hallway unsafely running into other residents and wall due to downward gaze and unawareness of surroundings Resident wanting to crawl in floor at night resident continues to remove covers off room mate and crawling in floor under bed .Team recommendations OOB in lowrider with self releasing belt, bed in lowest position with vest restraint .resident has stooped posture with shuffle fast paced gait with downward gaze abnormalities of gait and mobility .Dementia with behavioral disturbance wandering restlessness with agitation no safety awareness . Documentation of the meeting showed it was attended by the DON, QA RN, and the DOR. During an observation on [DATE] at 8:30 AM, in the Resident #18's room, showed Resident #18 seated in a lowrider with a SR [self-release] belt in place. The resident was unable to remove the belt upon request. During an observation on [DATE] at 1:35 PM, of Resident #18 in the resident's room, showed Resident #18 lying in bed with a shirt like vest restraint with fabric ties over the abdomen on the bottom of the vest and tied to both sides of the moveable part of the bed frame towards the head of the bed, with the resident resting with her eyes closed. Review of the medical record showed Resident #9 was admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy, Dementia, and Muscle Weakness The review showed Resident #9 expired at the facility on [DATE]. Review of the comprehensive MDS assessment dated [DATE], showed Resident #9's BIMS score was 9 indicating the resident was moderately cognitively impaired and the resident required assistance of one or more persons with ADL's. Review of facility documentation for Resident #9 showed XXX[DATE] .Time 00:40 AM [12:40 AM] .Resident found laying on bed frame of other bed in room .INTERVENTION (To Prevent Reoccurrence) Sent to ER [emergency room], OOB in lowrider with pelvic bed in lowest position with vest, observe Q 30 minutes release Q 2 hours . Review of a physician's order for Resident #9 dated [DATE], showed .OOB in lowrider with pelvic restraint .bed in lowest position with vest restraint .Start date; [DATE] D/C [discontinue] date [DATE] . Review of the initial restraint review form for Resident #9 dated [DATE], showed .Type of device: OOB in lowrider with pelvic, bed in lowest position with vests .NEW RESTRAINT ORDER .Resident with continued delusions and hallucinations, ambulating with shuffled downward gaze bumping into walls and other residents with mumbled speech. Constant redirection provided by staff .poor truck control .fast stopping shuffled downward gaze gait, abnormalities of gait .delusional disorder, hallucination, dementia .BIMS 10 . Documentation showed the DON, ADON, RN QA Nurse, and the DOR attended the meeting. Review of the last restraint review form for Resident #9 dated [DATE] [4 weeks after initial restraint], showed .pelvic in low rider, vest in bed .attempts made at reduction .reduced to clip belt but was unsuccessful resident was noted multiple times ambulating unsafely due to downward gaze walking into other residents, resident continues with hallucinations, delusions and mumbled speech .Vest was removed while in bed was unsuccessful Resident noted walking into walls, attempting to climb onto heating unit in room and climbing into room mates bed .Team recommendations pelvic in lowrider, vest in bed observe q30 minutes release q2 hours . The review showed the DON, ADON, RN QA Nurse, and the DOR attended the meeting. During an interview on [DATE] at 2:15 PM, the ADON stated .for [Resident #18] she's got the vest in bed at night time because she will be all over other residents .she will climb in the bed with them and pull off their cover .she has the SR belt during the day but she can't release it .she has it to make sure that she is not getting up, when she walks she looks straight down and she runs into things .with [Resident #21] .she might fiddle with it [SR belt] and release it .she doesn't release it on command . During an interview on [DATE] at 9:30 AM, the DOR stated .what we [the facility] have available to use are the self-release belts, the soft belts [padded belt that goes around the waist and attaches to a chair] the vest restraint, pelvic restraint, the table top [table top that attaches to chair] we don't have any chair or bed alarms we don't have lap buddies [soft table top], we don't have any of the Velcro belts .usually the vest restraint is something that is used in bed and that's two different surfaces that's why we use the self-release belt and the vest restraint . During an interview on [DATE] at 2:00 PM, the DON stated .his [Resident #13's] family wanted him at a facility closer to home but nobody [no other facility] would take him with the restraint so it was d/c'd [discontinued] on [DATE] [[DATE]] and it went pretty good he done really well .he was on hospice and he had a steady decline he was sleeping more and he was less active .the bed alarm is less restrictive than the vest but when it goes off it scares them [residents] .we could order them but we just haven't .I can't think of another device we could use in the bed I don't know what else we could have done .[Resident #9] had a fall we did the pelvic and the vest to keep her from falling .She Resident #18] will go over and pull the covers off of her roommate .with the vest it just keeps her from getting out of bed it doesn't allow her to physically stand from the bed .no we haven't put her in a private room .[given name for Resident #21] just has the SR belt she doesn't have anything in bed .it is on because she thinks she can get up and walk but she can't .no we haven't increased supervision or tried one on one [one on one supervision] .We continued to use the restraints for their safety[referring to Residents #13, #9, #18, and #21] . confirming the facility failed to recognize and use the least restrictive interventions or restraint device for the least amount of time. The facility's corrective actions were validated onsite by the surveyor on [DATE]. The corrective action plan included a Root Cause Analysis (RCA) and was completed by the Administrator and Director of Nursing on [DATE]. Review of the RCA showed: Facility staff did not ensure that they were up to date with regulations under the Requirements of Participation. Administration process in facility failed to identify deficient practice timely. Facility failed to follow restraint policy by not using least restrictive restraint device first. Review of the corrective action plan showed: Immediate action(s) taken for the resident(s) found to have been affected include: 1) Resident #18 - Interdisciplinary team which consisted of Director of Nursing (DON), Assistant Director of Nursing (ADON), Quality Assurance Nurse, and Therapy Department Manager [Director of Rehabilitation] completed assessment for safe restraint reduction completed on [DATE]. Restraint was discontinued in the chair and bed as of [DATE] at 1800 (6:00 PM). New order for out of bed in lowrider with dycem. Family and staff made aware of new orders. Resident was moved into private room. Care Plan updated to reflect changes Medical Director (MD) approved [DATE]. Resident was reviewed with the State Quality Manager from Alliant Health (QIO) on [DATE] at 1400 (2:00 PM) via conference call. 2) Resident #21 - Interdisciplinary team which consisted of DON, ADON, QA Nurse, and Therapy Department Manager completed assessment for safe restraint reduction completed on [DATE] restraint was discontinued in chair as of [DATE] at 1800 (6:00 PM). New order for out of bed in rock-n-go with dycem. Family and staff made aware of new order. Care plan updated to reflect changes MD approved [DATE]. Therapy screen requested for chair evaluation on [DATE], new order to discontinue out of bed in rock-n-go chair with dycem, and new order given for out of bed in low rider with dycem. Family and staff made aware of new orders. Care plan to reflect changes. Resident was reviewed with the State Quality Manager from Alliant Health (QIO) on [DATE] at 1400 (2:00 PM) via conference call. 3) Resident #13: discharged from facility [DATE]. 4) Resident #9: discharged from facility [DATE]. 5) A new policy established Restraint Free Environment for the facility and education of the new policy was implemented [DATE]. 6) The date of assured compliance was [DATE]. Identification of other residents having the potential to be affected was accomplished by: The facility has determined 86 out of 86 residents have the potential to be affected. All rooms were evaluated to ensure no restraints were being used. Restraints (self-releasing clip belts, soft lap belts, pelvic restraints and table tops) that are kept in clean linen room were removed and placed in the DON office by DON, ADON, QA Nurse, and Maintenance Director on [DATE] at 1900 (7:00 PM). Self-releasing clip belts, soft lap belts, pelvic restraints, vest restraints and table tops will be kept in the DON's office. Education was given on the new policy Restraint Free Environment at 1800 (6:00 PM) on [DATE] with the current clinical staff on shift (RN, LPN, CNA) and will be completed with all other remaining clinical staff (RN, LPN, CNA), providers (MD [Medical Director], DO [Doctor of Osteopathy and NPs [Nurse Practitioner]) and therapy department managers (PT [Physical Therapy], OT [Occupational Therapy], ST [Speech Therapy]) before next scheduled shift. Education was 100% completed by 22:30 [10:30 PM] on [DATE] Future employees will be educated as part of new hire orientation on restraint free environment and will reoccur quarterly. Review of facility's inservice sign-in sheets dated [DATE], for the Restraint Free Environment showed Education provided via phone dated [DATE], compared to the facility's list of clinical staff and list of (medical) providers and therapy managers and interviews with 2 night shift (6:00 PM - 6:00 AM) RNs, 2 night shift CNAs, 2 day shift LPNs (6:00 AM, 6:00 PM), 1 day shift RN, 3 day shift CNAs, 1 Occupational Therapist (OT), 1 Physical Therapist (PT), and 1 NP showed 100% of clinical staff and providers were educated on the new policy by the DON, ADON, and QA RN. A copy of the Restraint Free Environment policy were sent via mail to the residents' families on [DATE]. Education on all aspects of the requirements for restraint use was provided by the Clinical Consultant to all clinical management team members (Administrator, DON, ADON, MDS Coordinators, QA Nurse, Wound Care Nurse, and Therapy Manager) and was 100% completed by [DATE] at 17:30 (5:30 PM). The Clinical Consultant is available to facility clinical administration (Administrator, DON, ADON, MDS Coordinators, QA Nurse, Wound Care Nurse, and Therapy Manager) 24 hours a day, 7 days a week beginning on [DATE]. Review of Interdisciplinary Team (IDT) restraint reduction meeting minutes dated [DATE], showed the DON, ADON, QA Nurse, and Therapy Department Manager reviewed Resident #18 for restraint reduction and agreed with discontinuation of the restraint in the bed and in the chair with new orders as below. Review of a physician's order dated [DATE], for Resident #18 showed orders for self-release clip belt while out of bed and vest restraint while in bed were discontinued with the resident's new order as follows .OOB [out of bed] IN LOWRIDER WITH DYCEM every shift. Review of a progress note dated [DATE], for Resident #18 showed the resident's family was informed and agreeable to the above new orders. Review of Resident 18's care plan showed it was updated to reflect the changes that addressed restraints on [DATE]. Observation on [DATE] at 10:30 AM, showed the resident on the 100 hall near the nurses station in a low rider with dycem on the seat of the lowrider continued observation showed the resident was moved to a room with no other resident. Interview with the DON on [DATE] at 10:50 AM, confirmed Resident #18 was moved to a private room. Review of IDT restraint reduction meeting minutes for Resident #21 dated [DATE], showed the DON, ADON, QA Nurse, and Therapy Department Manager reviewed Resident #21 for restraint reduction and agreed to discontinuation of self-release belt in low rider and attempt reduction with resident placed in rock-n-go chair with dycem in seat due to noticeable reduction in attempts to get out of chair or transfer independently. Review of a Therapy Screen and Rehab Services Approval form dated [DATE] for Resident #21 showed the resident was screened by therapy with recommendation for lowrider. Review of physician's order dated [DATE] for Resident #21 showed self-release clip belt while out of bed was discontinued. Review of a physician's order dated [DATE] for Resident #21 showed .OOB IN LOWRIDER WITH DYCEM IN SEAT . Review of a Therapy Screen and Rehab Services Approval form dated [DATE], for Resident #21 showed .assessment .low rider with propulsion wheels to increase self-propulsion and mobility .to achieve optimal positioning . Review of a physician's order dated [DATE] for Resident #21 showed .OOB in lowrider with dycem in seat . Review of a progress note dated [DATE], for Resident #21 showed family was aware of the discontinued clip belt and the new order for the lowrider chair. Review of Resident 21's care plan showed the care plan was updated to reflect the changes made after the therapy screening on [DATE]. Observation on [DATE] at 11:15 AM, in Resident 21's room, showed the resident up in a lowrider with dycem in the seat of the chair. During a phone interview on [DATE], at 2:00 PM, with the State Quality Manager, she verified Residents #18 and #21 were reviewed with her on [DATE]. Observation on [DATE] at 12:30 PM, in the DON's office showed 2 self-release clip belts, 2 soft lap belts, 2 pelvic restraints, and 2 vest restraints, in a drawer and 1 tabletop restraint beside a filing cabinet secured in the DON's office. Interviews on [DATE]-[DATE], at various times, with 2 night shift (6:00 PM - 6:00 AM) Registered Nurses (RN), 2 night shift Certified Nurse Assistants (CNA), 2 day shift Licensed Practical Nurses (LPN) (6:00 AM, 6:00 PM), 1 day shift RN, 3 day shift CNAs, 1 Occupational Therapist (OT), 1 Physical Therapist (PT), and 1 Nurse Practitioner showed 100% of clinical staff and providers were educated on the new policy by the DON, ADON, and QA RN. Review of the facility's census roster dated [DATE], showed all residents were checked off as having .responsible party notification of new policy letters sent. During an interview on [DATE] at 1:00 PM, the Social Services Director confirmed all residents' responsible parties were sent letters of the new policy. Review of facility's STATEMENT OF INSERVICE TRAINING FOR EMPLOYEES showed 100% of administrative staff were educated on all aspects of the requirements for restraint use by the Clinical Consultant via conference call on [DATE] at 17:30 (5:30 PM). Review of a letter of engagement . dated [DATE], showed an ongoing contractual agreement for clinical consulting services to be provided to the facility through [DATE], or until terminated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of facility documentation, medical record review, observation, and interview, the facility failed to recognize and use the least restrictive interventions or restraint device for the least amount of time and failed to attempt a reduction to a least restrictive device or eliminate the restraint devices during the 30-day assessments. The facility's failure to recognize and use the least restrictive interventions or restraint device for the least amount of time and failure to attempt a reduction to a least restrictive device or eliminate the restraint devices during the 30-day assessments resulted in 4 of 29 sampled residents (Resident #9, #13, #18, and #21) being placed in restraints that were not the least restrictive for an extended amount of time. The findings include: Review of the facility's undated policy titled, POLICY AND PROCEDURE FOR RESTRAINTS AND SAFETY DEVICES showed .Facility will use the least restrictive safety device or restraint to ensure safety of the resident .Interdisciplinary team will meet once a week to .Decrease safety devices and restraints if no incident in last 30 days .will ensure that the least restrictive safety device or restraint is used for the least amount of time to ensure resident safety . Review of the medical record showed Resident #13 was admitted to the facility on [DATE] with diagnoses including Dementia, Bipolar Disorder, and Anxiety Disorder. Resident #13 was discharged to another facility on [DATE]. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] showed Resident #13's Brief Interview of Mental Status (BIMS) score was 0 indicating the resident had severe cognitive impairment and the resident required assistance of one or more persons with activities of daily living (ADL's). Review of a physician's order for Resident #13 dated [DATE] showed .BED IN LOWEST POSITION WITH VEST RESTRAINT .for 30 days . Review of the initial restraint review form for Resident #13 dated [DATE] (2 days after admission), showed .Type of device: BED IN LOWEST POSITION WITH VEST RESTRAINT [vest with tie-ends for bed or chair application/most restrictive device] .RESIDENT HAS HAD CONFUSION AND RECENT DIAGNOSIS OF PNA [Pneumonia] AND STARTED ABX [antibiotic] RESIDENT HAS HAD MULTIPLE ATTEMPTS OUT OF BED UNSAFELY AND IS WAKING UP ROOMMATE RESIDENT IS STANDING OVER ROOMMATE AND IS TRYING TO CLIMB INTO THEIR BED .POOR TRUNK CONTROL .UNSTEADY GAIT AND BALANCE, RESIDENT LEANS TO RIGHT SIDE WHILE AMBULATING AND KEEPS HEAD IN DOWNWARD POSITION .IMPULSIVENESS AND DECREASED SAFETY AWARENESS DUE TO SENIL DEGENERATION OF BRAIN, DEMENTIA .NOT AWARE OF SURROUNDINGS, OTHER RESIDENTS, OR SITUATIONS, ALERT TO SELF ONLY .GENERALIZED WEAKNESS NOTED TO BILATERAL LOWER EXTREMITIES .REEVALUATE IN 30 DAYS OR PRN [as needed] . Documentation on the initial restraint review showed the Director of Nursing (DON), Quality Assurance (QA) Registered Nurse (RN), and the Director of Rehabilitation (DOR) attended the meeting. Review of the final 30 day restraint review form for Resident #13 dated [DATE] [26 weeks after initial restraint], showed .Type of device: SR [self release] BELT IN CHAIR VEST IN BED .attempts made at reduction UNSUCCESSFUL [no attempts listed on form see progress note below] .Team recommendations; OOB [out of bed] IN ROCK-N- GO [rocking wheelchair] W [with]/SR BELT .BED IN LOWEST POSITION W/VEST RESTRAINT . Review of a Restraints MEETING MINUTES form dated [DATE], showed .[Resident #13] cognition continues to decline .noted with less physical activity .resident has shown no signs of attempting to self transfer since last assessment Resident is sleeping throughout the night with no attempts to exit the bed .attempt restraint reduction at this time .[Medical Director] MD notified and agrees . Review of a physician's order for Resident #13 showed the residents restraints were discontinued on [DATE] with no new orders for restraints noted showing Resident #1 went from the most restrictive restraint device to no restraints in use. Review of the medical record showed Resident #21 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Dementia, and Abnormalities of Gait. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] showed Resident #21's Brief Interview of Mental Status (BIMS) score was 6, indicating severe cognitive impairment and the resident required assistance of one or more persons for ADL's. Review of a physician's order for Resident #21 dated [DATE], showed .OOB in lowrider with pelvic restraint [restraint for chair use/most restrictive chair restraint] .bed in lowest position with vest restraint . Review of the initial restraint review form for Resident #21 dated [DATE], showed .OOB in low rider [wheelchair that sits low] with pelvic restraint bed in lowest position with vest restraint .new restraint .comments .Resident continues to slide down in chair despite dycem [nonslip material] being placed in chair, resident leans over right side over chair multiple attempts made to reposition in chair to remain in upright position .at night resident unsafely ambulates in room pulling covers off roommate and attempting to climb into roommates bed stating this is her house .alternatives attempted Team recommendations: OOB in lowrider with pelvic restraint, bed in lowest position with vest restraint .dycem in chair between cushion and chair .resident has poor trunk control slides to edge of chair .dementia with agitation and behavioral disturbance anxiety disorder .diffuse traumatic brain injury .generalized muscle weakness . the meeting's signatures showed it was attended by the DON, ADON, QA RN, and the DOR. Review of the most recent 30 day restraint review form for Resident #21 dated [DATE] [12 weeks after initial restraint], showed .Type of device OOB in lowrider with self releasing clip belt .attempts made at reduction .self release clip belt was discontinued however was unsuccessful resident noted sliding down in chair due to no trunk control or upper body strength Resident thinks she can still self transfer however she has no strength or safety awareness .Team recommendations OOB in low rider with self releasing clip belt .dementia with agitation and behavioral disturbance, .psychotic disorder, .diffuse traumatic brain injury .generalized muscle weakness receives hospice services . Documentation showed the meeting was attended by the DON, QA RN, and the DOR. During an observation on [DATE] at 8:00 AM, in Resident #21's room, showed Resident #21 seated in a lowrider with SR belt on and the resident was unable to remove the belt. Review of the medical record showed Resident #18 was admitted to the facility on [DATE] with diagnoses including Dementia, Abnormalities of Gait, and Dissociative Fugue [temporary state of memory loss]. Review of the quarterly MDS assessment dated [DATE] showed Resident #18's BIMS score was 0 indicating the resident had severe cognitive impairment and the resident required assistance of one or more persons with ADL's. Review of a physician's order for Resident #18 dated [DATE] showed .OOB in lowrider with self releasing clip belt . Review of the initial restraint review form for Resident #18 dated [DATE] showed .Type of device; lowrider with self releasing clip belt .new order .Team recommendations: lowrider with self releasing clip belt observe q 30 minutes release q2 hours for toileting and exercise periods for decreased safety awareness . Documentation of the initial restraint review meeting showed it was attended by the DON, ADON, QA RN, and the DOR. Review of the most recent 30 day restraint review form for Resident #18 dated [DATE] [32 weeks after initial restraint], showed .Type of device .Team recommendations OOB in lowrider with self releasing belt, bed in lowest position with vest restraint .no safety awareness . The signatures showed the meeting was attended by the DON, QA RN, and the DOR. During an observation on [DATE], at 8:30 AM, in the resident's room, showed Resident #18 seated in a lowrider with a SR belt on the resident and the resident was unable to remove the belt. During an observation on [DATE] at 1:35 PM, of Resident #18, in the resident's room, showed the resident in bed with a shirt like vest restraint with fabric ties over the abdomen on the bottom of the vest and tied to both sides of the moveable part of the bed frame at the head of the bed the resident was resting with her eyes closed. Review of the medical record showed Resident #9 was admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy, Dementia, and Muscle Weakness, Review showed Resident #9 expired at the facility on [DATE]. Review of the comprehensive MDS assessment dated [DATE] showed Resident #9's BIMS score was 9 indicating the resident was moderately cognitively impaired. The resident required assistance of one or more persons with ADL's. Review of a facility document for Resident #9 showed XXX[DATE] .Time 00:40 AM [12:40 AM] .Resident found laying on bed frame of other bed in room .INTERVENTION (To Prevent Reoccurrence) Sent to ER, OOB in lowrider with pelvic bed in lowest position with vest, observe Q 30 minutes release Q 2 hours . Review of a physician's order for Resident #9 dated [DATE] showed .OOB in lowrider with pelvic restraint .bed in lowest position with vest restraint .Start date; [DATE] D/C [discontinue] date [DATE] . Review of the initial restraint review form for Resident #9 dated [DATE] showed .Type of device: OOB in lowrider with pelvic, bed in lowest position with vest . NEW RESTRAINT ORDER . Review of the documentation showed the DON, ADON, RN QA Nurse, and the DOR attended the meeting. Review of the next restraint review form for Resident #9 dated [DATE] [4 weeks after initial restraint], showed .pelvic in low rider, vest in bed .attempts made at reduction .reduced to clip belt but was unsuccessful resident was noted multiple times ambulating unsafely due to downward gaze walking into other residents, resident continues with hallucinations, delusions and mumbled speech .Vest was removed while in bed was unsuccessful Resident noted walking into walls, attempting to climb onto heating unit in room and climbing into room mates bed .Team recommendations pelvic in lowrider, vest in bed .CONTINUE CURRENT POC AND REVIEW IN 30 DAYS AND PRN . The documentation showed the DON, ADON, RN QA Nurse, and the DOR attended the meeting. During an interview on [DATE] at 2:15 PM, the ADON stated .for [Resident #18] she's got the vest in bed at night time because she will be all over other residents she will climb in the bed with them and pull off their cover .she has the SR belt during the day but she can't release it she has it to make sure that she is not getting up when she walks she looks straight down and she runs into things .with [Resident #21] .she might fiddle with it [SR belt] and release it she doesn't release it on command . During an interview on [DATE] at 9:30 AM, the DOR stated .what we have available to use are the self-release belts, the soft belts [padded belt that goes around the waist and attaches to a chair] the vest restraint, pelvic restraint, the table top [table top that attaches to chair] we don't have any chair or bed alarms we don't have lap buddies [soft table top], we don't have any of the Velcro belts .usually the vest restraint is something that is used in bed and that's two different surfaces that's why we use the self-release belt and the vest restraint . During an interview on [DATE] at 2:00 PM, the DON stated .his [Resident #13's] family wanted him at a facility closer to home but nobody would take him with the restraint, so it was d/c'd on [DATE] [[DATE]] and it went pretty good he done really well .he was on hospice and he had a steady decline he was sleeping more and he was less active .the bed alarm is less restrictive than the vest but when it goes off it scares them [residents] .we could order them but we just haven't .I can't think of another device we could use in the bed I don't know what else we could have done .[Resident #9] had a fall we did the pelvic and the vest to keep her from falling .[Resident #18] She will go over and pull the covers off of her roommate .with the vest it just keeps her from getting out of bed it doesn't allow her to physically stand from the bed .no we haven't put her in a private room .[NAME] #21 just has the SR belt she doesn't have anything in bed .it is on because she thinks she can get up and walk but she can't .no we haven't increased supervision or tried one on one [one on one supervision] we continued to use the restraints for their safety [Residents #13, #9, #18, and #21] . confirming the facility's administration failed to recognize and use the least restrictive interventions or restraint device for the least amount of time. The facility's corrective actions were validated onsite by the surveyor on [DATE]. The corrective action plan included a Root Cause Analysis (RCA) and was completed by the Administrator and Director of Nursing on [DATE]. Review of the RCA showed: Facility staff did not ensure that they were up to date with regulations under the Requirements of Participation. Administration process in facility failed to identify deficient practice timely. Facility failed to follow restraint policy by not using least restrictive restraint device first. Review of the corrective action plan showed: Immediate action(s) taken for the resident(s) found to have been affected include: 1) Resident #18 - Interdisciplinary team which consisted of Director of Nursing (DON), Assistant Director of Nursing (ADON), Quality Assurance Nurse, and Therapy Department Manager [Director of Rehabilitation] completed assessment for safe restraint reduction completed on [DATE]. Restraint was discontinued in the chair and bed as of [DATE] at 1800 (6:00 PM). New order for out of bed in lowrider with dycem. Family and staff made aware of new orders. Resident was moved into private room. Care Plan updated to reflect changes Medical Director (MD) approved [DATE]. Resident was reviewed with the State Quality Manager from Alliant Health (QIO) on [DATE] at 1400 (2:00 PM) via conference call. 2) Resident #21 - Interdisciplinary team which consisted of DON, ADON, QA Nurse, and Therapy Department Manager completed assessment for safe restraint reduction completed on [DATE] restraint was discontinued in chair as of [DATE] at 1800 (6:00 PM). New order for out of bed in rock-n-go with dycem. Family and staff made aware of new order. Care plan updated to reflect changes MD approved [DATE]. Therapy screen requested for chair evaluation on [DATE], new order to discontinue out of bed in rock-n-go chair with dycem, and new order given for out of bed in low rider with dycem. Family and staff made aware of new orders. Care plan to reflect changes. Resident was reviewed with the State Quality Manager from Alliant Health (QIO) on [DATE] at 1400 (2:00 PM) via conference call. 3) Resident #13: discharged from facility [DATE]. 4) Resident #9: discharged from facility [DATE]. 5) A new policy established Restraint Free Environment for the facility and education of the new policy was implemented [DATE]. 6) The date of assured compliance was [DATE]. Identification of other residents having the potential to be affected was accomplished by: The facility has determined 86 out of 86 residents have the potential to be affected. All rooms were evaluated to ensure no restraints were being used. Restraints (self-releasing clip belts, soft lap belts, pelvic restraints and table tops) that are kept in clean linen room were removed and placed in the DON office by DON, ADON, QA Nurse, and Maintenance Director on [DATE] at 1900 (7:00 PM). Self-releasing clip belts, soft lap belts, pelvic restraints, vest restraints and table tops will be kept in the DON's office. Education was given on the new policy Restraint Free Environment at 1800 (6:00 PM) on [DATE] with the current clinical staff on shift (RN, LPN, CNA) and will be completed with all other remaining clinical staff (RN, LPN, CNA), providers (MD [Medical Director], DO [Doctor of Osteopathy and NPs [Nurse Practitioner]) and therapy department managers (PT [Physical Therapy], OT [Occupational Therapy], ST [Speech Therapy]) before next scheduled shift. Education was 100% completed by 22:30 [10:30 PM] on [DATE] Future employees will be educated as part of new hire orientation on restraint free environment and will reoccur quarterly. Review of facility's inservice sign-in sheets dated [DATE], for the Restraint Free Environment showed Education provided via phone dated [DATE], compared to the facility's list of clinical staff and list of (medical) providers and therapy managers and interviews with 2 night shift (6:00 PM - 6:00 AM) RNs, 2 night shift CNAs, 2 day shift LPNs (6:00 AM, 6:00 PM), 1 day shift RN, 3 day shift CNAs, 1 Occupational Therapist (OT), 1 Physical Therapist (PT), and 1 NP showed 100% of clinical staff and providers were educated on the new policy by the DON, ADON, and QA RN. A copy of the Restraint Free Environment policy were sent via mail to the residents' families on [DATE]. Education on all aspects of the requirements for restraint use was provided by the Clinical Consultant to all clinical management team members (Administrator, DON, ADON, MDS Coordinators, QA Nurse, Wound Care Nurse, and Therapy Manager) and was 100% completed by [DATE] at 17:30 (5:30 PM). The Clinical Consultant is available to facility clinical administration (Administrator, DON, ADON, MDS Coordinators, QA Nurse, Wound Care Nurse, and Therapy Manager) 24 hours a day, 7 days a week beginning on [DATE]. Review of Interdisciplinary Team (IDT) restraint reduction meeting minutes dated [DATE], showed the DON, ADON, QA Nurse, and Therapy Department Manager reviewed Resident #18 for restraint reduction and agreed with discontinuation of the restraint in the bed and in the chair with new orders as below. Review of a physician's order dated [DATE], for Resident #18 showed orders for self-release clip belt while out of bed and vest restraint while in bed were discontinued with the resident's new order as follows .OOB [out of bed] IN LOWRIDER WITH DYCEM every shift. Review of a progress note dated [DATE], for Resident #18 showed the resident's family was informed and agreeable to the above new orders. Review of Resident 18's care plan showed it was updated to reflect the changes that addressed restraints on [DATE]. During an interview on [DATE] at 10:50 AM, the DON confirmed Resident #18 was moved to a private room. Review of IDT restraint reduction meeting minutes for Resident #21 dated [DATE], showed the DON, ADON, QA Nurse, and Therapy Department Manager reviewed Resident #21 for restraint reduction and agreed to discontinuation of self-release belt in low rider and attempt reduction with resident placed in rock-n-go chair with dycem in seat due to noticeable reduction in attempts to get out of chair or transfer independently. Review of a Therapy Screen and Rehab Services Approval form dated [DATE] for Resident #21 showed the resident was screened by therapy with recommendation for lowrider. Review of physician's order dated [DATE] for Resident #21 showed self-release clip belt while out of bed was discontinued. Review of a physician's order dated [DATE] for Resident #21 showed .OOB IN LOWRIDER WITH DYCEM IN SEAT . Review of a Therapy Screen and Rehab Services Approval form dated [DATE], for Resident #21 showed .assessment .low rider with propulsion wheels to increase self-propulsion and mobility .to achieve optimal positioning . Review of a physician's order dated [DATE] for Resident #21 showed .OOB in lowrider with dycem in seat . Review of a progress note dated [DATE], for Resident #21 showed family was aware of the discontinued clip belt and the new order for the lowrider chair. Review of Resident 21's care plan showed the care plan was updated to reflect the changes made after the therapy screening on [DATE]. Observation on [DATE] at 11:15 AM, in Resident 21's room, showed the resident up in a lowrider with dycem in the seat of the chair. During a phone interview on [DATE], at 2:00 PM, with the State Quality Manager, she verified Residents #18 and #21 were reviewed with her on [DATE]. Observation on [DATE] at 12:30 PM, in the DON's office showed 2 self-release clip belts, 2 soft lap belts, 2 pelvic restraints, and 2 vest restraints, in a drawer and 1 tabletop restraint beside a filing cabinet secured in the DON's office. Interviews on [DATE]-[DATE], at various times, with 2 night shift (6:00 PM - 6:00 AM) Registered Nurses (RN), 2 night shift Certified Nurse Assistants (CNA), 2 day shift Licensed Practical Nurses (LPN) (6:00 AM, 6:00 PM), 1 day shift RN, 3 day shift CNAs, 1 Occupational Therapist (OT), 1 Physical Therapist (PT), and 1 Nurse Practitioner showed 100% of clinical staff and providers were educated on the new policy by the DON, ADON, and QA RN. Review of the facility's census roster dated [DATE], showed all residents were checked off as having .responsible party notification of new policy letters sent. During an interview on [DATE] at 1:00 PM, the Social Services Director confirmed all residents' responsible parties were sent letters of the new policy. Review of facility's STATEMENT OF INSERVICE TRAINING FOR EMPLOYEES showed 100% of administrative staff were educated on all aspects of the requirements for restraint use by the Clinical Consultant via conference call on [DATE] at 17:30 (5:30 PM). Review of a letter of engagement . dated [DATE], showed an ongoing contractual agreement for clinical consulting services to be provided to the facility through [DATE], or until terminated.