**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from physical restraints for 1 (Resident #1) of 31 residents reviewed for physical restraints. The facility failed to inform Resident #1 or their representative of the risks associated with use of assist bars, care plan for risks associated with assist bars/bed rails, obtain consent for the use of assist bars, obtain physician orders for use of assist bars, and implement interventions following an incident of entrapment with the assist bar. Resident #1 was found by LVN A on the floor in his room with his left arm caught between the assist bar and air mattress on 09/24/2023 and had no interventions to address risk of entrapment following incident. Resident #1 was found by CNA A in his room with his left arm, head and neck between the assist bar and air mattress and his legs on the floor mat on 10/31/2023 and CPR was initiated. Resident #1 expired at the hospital on [DATE] following intubation and responsible party withdraw of care. An IJ was identified on 11/03/2023. The IJ template was provided to the facility on [DATE] at 3:40 p.m. While the IJ was removed on 11/05/2023, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for entrapment with serious injury or death. Findings included: 1. Record review of Resident #1's face sheet, dated 11/02/2023, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included repeated falls, epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors), congenital stenosis (abnormal spinal narrowing present at birth) and obstruction of esophagus, age related physical debility, spastic hemiplegia (muscles on one side of the body being in a constant state of contraction) affecting left nondominant side, dizziness and giddiness, and general muscle wasting and atrophy. Record review of Physician Orders dated 11/02/2023, reflected Resident #1 had no orders for assist bars. Record review of Resident #1 ' s Progress Notes, between August 2023 through October 2023, reflected Resident #1 had a fall on 09/24/2023 in his room and was found by LVN B with his left arm between the assist bar and bed. There were no bed safety assessments for use of assist bars on or after 9/24/2023. The resident had an additional fall in his room on 10/31/2023 and was found unresponsive by CNA A and appeared grey in color with his left arm, head and neck between the assist bar and air mattress with his legs on the floor mat and CPR was immediately initiated by RN R at 6:50 p.m. EMS was called and arrived at 6:58 p.m. and Resident #1 was transferred to the hospital. Record review of Resident #1 ' s care plan, revised 08/11/2023, reflected the resident had a history of falls and seizures with interventions to include: review information on past falls, attempt to determine cause of falls, record possible root causes, alter/remove any potential causes, if possible, educate resident/family/caregivers/IDT about causes, safety reminders and what to do if fall occurs, attempt to find the resident triggers for falls, attempting to self-toilet (initiate trial toileting program); confusion in the evening (encourage distraction activities in the evening); the resident needs a safe environment with even floors free from spills and/or clutter, and the bed in low position at night. The care plan did not address assist bars or risks associated with use of assist bars. Record review of Resident #1's most recent significant change in status MDS, dated [DATE], reflected he had a Brief Interview for Mental Status score of 03, which indicated severe cognitive impairment. Resident #1's functional status reflected he was non-ambulatory and required a two person assist for bed mobility. Record review of Resident #1's assessments between September 2023 and October 2023, reflected there were no bed safety assessments completed. Record review of incident report log between September 1, 2023 through November 3, 2023 reflected Resident #1 had a history of falls on 09/02/2023 at 11:13 p.m., three falls on 09/21/23 at 1:00 p.m., 1:30 p.m., and 1:45 p.m., one fall on 09/22/2023 at 10:45 p.m., one fall on 09/24/2023 at 2:00 p.m., one fall on 10/01/2023 at 1:45 a.m., two falls on 10/5/2023 at 2:25 a.m. and 7:45 p.m., one fall on 10/10/2023 at 12:45 a.m., two falls on 10/15/2023 at 10:42 a.m. and 7:00 p.m. and 10/16/2023 at 5:52 p.m. Record review of incident report written by LVN A, dated 09/24/2023 at 2:00 p.m., reflected Resident #1 was found sitting on the floor with back up against the bed with his left arm between the mattress and railing. Bed was in lowest position. Resident was able to move his arm from between the bed and railing with assistance Resident #1 had a small abrasion to his left elbow and front right knee, resident was assisted to bed with gait belt, and resident was unable to give a description. Record review of incident report written by RN R, dated 10/31/2023, reflected Resident #1 was found at approximately 6:50 p.m. by CNA A and noted to be .sitting on buttocks on floor with left arm around right-side bed rail and left side of neck/head lodged between mattress and side rail. Resident was grey in color, warm to touch and faint right-side jugular pul[s]e noted. [CNA A] notified this RN (RN R) that was across the hall at medication cart on resident's hall. I (RN R) entered room and [CNA A] and I placed resident on the floor and began CPR. [LVN T] called 911 and printed paperwork for EMS. I began chest compressions for 5 cycles while [CNA A] assisted with the [bag valve mask] and we swapped out after 5 cycles. [CNA B] joined in rotation. [AED] applied after 1 cycle of CPR. Directions followed and no shock advised. When paramedics arrived Resident O2 sats [were] 95% on O2 2L [nasal canula]. Contacted emergency contact [RP W], [MD], and [DON] in report incident. Record review of, undated, witness statement by CNA A reflected he was taking residents out for their evening smoke break when a resident notified him that Resident #1 was on the floor. He immediately went to the room and saw Resident #1's head almost stuck in the side rail and he looked pale. CNA A reported he notified RN R that Resident #1 looked pale and was nonresponsive and RN R stayed in the room while he ran to get the crash cart. RN R and CNA A proceeded to do chest compressions until the paramedics arrived. Record review of, undated, witness statement, did not document a name and date, reflected at approximately 6:50 p.m., CNA A noted resident sitting on buttocks on the floor with left arm around right-side rail and left side of head/neck lodged between mattress and side rail, resident was grey in color, warm to touch, and faint jugular pulse noted to right side. CNA A notified RN R that was at medication cart across from residents' room. The witness statement reflected: I (RN R) entered room and [CNA A] and I (RN R) placed resident on floor and began CPR. [LVN B] called 911 and printed paperwork for EMS. I began chest compressions for 5 cycles and [CNA A] used [bag valve mask] and we swapped after 5 cycles CNA B joined in the rotation 3 cycles in CPR performed 10 min. [AED] was applied after 1 cycle of CPR. Directions followed and no shock advised. When paramedics arrived resident O2 sat (oxygen saturation) was 95% on O2 2L (Liters) NC (Nasal Cannula). [RP W] contacted notified at [phone number] at 8:58 p.m. by RN A. She stated he is not DNR and is in the process of being placed on Hospice. Record review of Resident #1's hospital records, dated 11/01/2023, reflected he presented to the ER post cardiac arrest, and he was found after he slid out of his bed with his head in the bed rail. When nursing found the resident, he did not have a pulse, CPR was initiated, upon EMS arrival patient had a pulse, and intubation was attempted but unable to place in a definitive airway. A transfer to other acute facility was ordered for a higher level of care due to acute exacerbation (worsening of airway function). Record review of the Provider Investigation Report, dated 11/02/2023, reflected the following: .At approximately 1850 [6:50 p.m.] [CNA A] noted resident sitting on buttocks on floor with left arm around right side bed rail and left side of neck/head between mattress and side rail with chin resting on side rail. and Resident was noted to be sitting on buttocks on floor with left arm around right side of bed rail and left side rail and left side of neck/head lodged between mattress and side rail .resident was grey in color, warm to touch and faint right side jugular pulse noted . Provider Response [RN A] with the assistance of [CNA A] placed resident on the floor and began CPR while the other duty called 911 and prepared papers for transfer. RN began chest compressions for 5 cycles while CNA assisted with the [bag valve mask] bag and they swapped out after 5 cycles. [CNA B] assisted in the rotation. AED applied after first cycle fo CPR with no shock advised. When EMS on scene resident had O2 saturation of 95% on NC (nasal cannula) [at] 2/L O2 and a heartbeat was present. Resident placed on stretcher and transported out of facility. Resident emergency contact and attending physician notified of incident and transport by EMS. Investigation Summary Staff present/assisting with the emergency were interviewed. Statements have been and are being obtained. Staff member who was first on scene (CNA A) demonstrated exactly what he saw when entering resident room. The demonstration reveals the left arm between assist rail and mattress with head resting upon left shoulder and chin resident on the side rail, the neck free from pressure/compression. Upon interview [CNA A] indicated that when he entered the resident room the resident's neck/airway was not compromised and his chin was resting on the side rail .his shoulder blades and head were pressed in the area, but his neck was totally free. [CNA A] stated they did lower the rail or deflate the mattress but rather lifted the resident carefully up and over, then onto the ground. [CNA A] stated, 'his neck was free .his oxygen tubing was not on his face but on the ground.' [Resident #1's] bed, mattress, and assist rails were evaluated by maintenance to ensure no malfunction and proper fit to meet FDA standards, all equipment was in good working order and the distance measured between the air mattress and the assist rail was 2.5 inches. All statements were reviewed/analyzed as well as the re-enactment demonstration and it is not confirmed that the resident suffered strangulation in the assist rail as there was no pressure noted to be on the resident's airway. It is not confirmed that neglect occurred as the resident had no more than an hour before the last interaction with staff and this incident. Resident has a history of self-transfer attempts and all measures to prevent injury were in place (bed in lowest position, fall mats at bedside, door left open, and call light within reach.) Record review of witness statement by CNA B, dated 11/3/2023 at 1:03 p.m., reflected the following: During my first rounds after clocking in I saw [Resident #1] in his bed awake, head of bed elevated, feet down. [Resident #1's] feet were hanging off the end of the bed, the sheets were on the floor. Resident repositioned in bed, new bedding on resident. Head elevated and feet elevated. Call light in reach. I continued on my rounds making my way down the halls. I was on the therapy hall when I hea[r]d [RN A] yell out HELP! Call 911 and got the crash cart. She and [CNA A] were looking for the [bag valve mask] bag, gave it to [RN A] and [CNA A] and I were rotating compressions. Doing roughly 2-3 each then switching. CPR for approximately 5-10 minutes before EMS arrived. They took over compressions, changed out the AED and got vital[s]. He was breathing when EMS arrived. During an interview on 11/02/2023 at 9:28 a.m., the Administrator and the DON said Maintenance was responsible for the bed and assist bar installation and maintenance. The Administrator said he was not sure who last saw Resident #1 but it had been within the hour and the resident was initially at the hospital for altered mental status and failure to thrive before he returned from the hospital a couple hours prior to incident. The Administrator said Resident #1 returned on 10/31/2023 at 4:00 p.m. and the incident occurred at 6:50 p.m. The Administrator and the DON said CNA A found him with his left arm, head and neck between the assist bar and air mattress with his legs on the floor. The Administrator and the DON said RN A assessed the resident and immediately began CPR, AED device was obtained, and resident was a full code when he returned from the hospital even though his RP had requested a DNR at the hospital, there was not a DNR in place prior to return. The Administrator and DON said EMS arrived and he was transported to the hospital and was anticipated to return on hospice. The Administrator and DON said the roommate was in the room but was unable to communicate and was not interviewable and RP W and attending physician were notified of the incident. During an observation on 11/02/2023 at 10:00 a.m., Resident #31, roommate of Resident #1, was lying in bed free from apparent injury and appeared confused. Resident #31 did not respond to questions and the room appeared free from hazards and no assist bars were installed to beds in the room. During an interview on 11/02/2023 at 11:36 AM, Maintenance said she had been employed at the facility for 3 years and was responsible for installation and maintenance of assist bars on beds. Maintenance said she did not know what happened to Resident #1 but was asked to measure the distance between the mattress to the grab bar. Maintenance said she took both bed rails and put them on the bed to see how far the mattress was able to move and measured the spacing to be 2 and a half inches. She was not aware of a facility policy for gap requirements between assist bars and beds and did not know where to find the information if needed but was asked to measure by the DON and corporate office. Maintenance said all beds and assist bars were the same except for geriatric beds. Maintenance said she had never measured the distance between the air mattress and bed before and 11/1/2023 was the first time she had measured it because she was not aware of the space requirements. Maintenance said she never noticed any gaps between the mattress and assist bar and did not recall specifically looking for that and no similar incidents of entrapment had happened that she was aware of. Maintenance said if there was a staff member requesting an assist bar, they grabbed them off the bed and there was a key that went to it and that was how it was assembled to the bed. Maintenance said maintenance requests were placed in the maintenance book at the nursing station and computer system. All staff looked at the beds every day and did not have a routine safety check scheduled and there were no issues with assist bars and the air mattress was sufficient size for Resident #1. Maintenance said she was not aware of the potential risks assist bars posed to residents. There was usually a physician's order to install assist bars and she was notified by the nurse and assist bars were in good condition and secure. Maintenance said it was important for assist bars to be installed appropriately because residents could have a fall and not be able to get up by themselves and couple pose a risk of entrapment. Maintenance said all residents were physically able to use assist bars. During an interview and record review on 11/02/2023 at 12:15 p.m., Maintenance provided an assist bar and observed attached warning label which indicated risk of entrapment to include. WARNING/SAFETY ALERT .Powered air mattress surfaces may pose a risk of entrapment. Prior to use, ensure the therapeutic benefits outweigh the risk of entrapment. Maintenance said there were residents with air mattresses and assist bars still at the facility and that the provided assist bar and manual, titled [Company L] Instructions For Use Service Manual, was used on all beds. Record review of Company L manual for the bed reflected optional assist bar installation instructions, on pg.17, indicating Power air mattress surfaces may pose a risk of entrapment. Prior to use, ensure the therapeutic benefits outweigh the risk of entrapment. During an interview via phone on 11/02/2023 at 2:00 p.m., RN R said she had been employed at the facility for a month and worked on Resident #1's hall. RN R said she was provided training on neglect via in-services but had not received training on assist bars following incident since she had not returned to work following the incident on 10/31/2023 with Resident #1. RN R said Resident #1 was discharged from the hospital on [DATE] and she tried to obtain orders for feeding since the hospital did not send any orders with him and she knew previously that he was a tube feeder. RN R said Resident #1 fell constantly and he was being monitored constantly by staff and had him up at the nurses station the majority of time at night. RN R said she obtained feeding orders and put everything on the medication cart to go down the hall and administered a pain pill to his neighbor when she walked past his room and he was laying in his room at baseline. RN R said she entered the neighbors room and administered medication then crossed the hall to administer medication to another resident when CNA A notified her she needed to come to Resident #1's room. RN R said when she walked in Resident 31's room he was on the right side of the bed and his left arm was wedged on the other side between the mattress and the arm rail and his head was lodged there on his left side. RN R said he was sitting on his buttocks with his legs out straight, arm in the rail and the corner of his head an inch in on the throat area with his head turned to the right. RN R said she removed the resident from the rail and administered 2 cycles fo CPR when his color started to come back. RN A said the other nurse on duty called 911 and paramedics arrived 8 minutes later. RN R said the defibrillator was placed on the resident and CPR continued. RN R said his oxygen saturations were at 95% and he came with oxygen from the hospital but when he left the facility to be transferred to the ER he was breathing on his own. RN R said the ambulance remained outside for 30 to 45 minutes before leaving and she assumed they were placing an IV line. RN R said she called the hospital and was informed he was intubated. RN A said she last saw the resident at 6:45 p.m. on 10/31/2023 when she told him she would be back to feed him. RN R said she notified the attending physician and representative of incident. RN R said Resident #1 had a history of rolling out of the bed while he was asleep, and she had not noticed any gaps between the assist bar and air mattress prior to this incident and she did not pay much attention to gap space requirements. RN R said it was important risks of assist bars were reviewed with residents to obtain consent and inform about the risks of entrapment if installed on air mattress beds. RN R said she had not returned to work since the incident and was supposed to have a meeting today about everything and she believed it was rescheduled for next week. RN R said she was not sure what space was allowed between the assist bar and air mattress, but she thought there should be no space in that zone. RN R said Maintenance was responsible for installing bed rails and all staff were responsible for checking bed safety on a routine basis, but RN R was not sure who did the assessment for assist bars and if she was responsible for completing and would have to consult with the DON. RN A said the IDT team was usually responsible for reviewing and obtaining orders for assist bars upon admission RN R said Resident #1 was able to physically use the assist bars for bed mobility. During an interview on 11/2/2023 at 3:58 p.m., the Administrator said a QAPI meeting was not conducted following the reported incident with Resident #1 and the meeting would be around the middle of November 2023. During an interview via phone on 11/02/2023 at 5:17 p.m., CNA A said on 10/31/2023 he found Resident #1 with his left arm, head and neck between the assist bar and mattress and the gap between the assist bar and bed appeared to be approximately 2 to 3 centimeters wide. CNA A said he last saw Resident #1 about 10 minutes prior to incident when he went in the room to remove his food tray and reported Resident #1 was at baseline. CNA A said he never saw him get stuck like that before in the assist bar. CNA A said he worked at the facility since the incident and had not received training on bed safety, and he felt training would be helpful. CNA A said he believed the gap amount allowed between the mattress and assist bar was 2 inches or 2 and half inches. CNA A said assist bars posed a risk of entrapment to all residents who were bed bound and on-air mattresses such as Resident #3 and it would be important for residents or representatives to know the risk of assist bars to include potential entrapment so they would have the knowledge needed to make the appropriate decision for use. CNA A said the nurses were responsible for ensuring bed safety but all staff could look at the beds and notify the nurse with any concerns. CNA A said he felt residents used the assist bars appropriately and only had a concern for resident with air mattresses and assist bars installed to bed that were not cognitively intact. CNA A said he did not know if residents were being notified of the potential risks with using assist bars and it would be the nurse's responsibility or the IDT team to do so upon admission. CNA A said he was not sure when the resident had his assist bars installed but CNA A had been at the facility for 2 years and believed the resident had always had them on his bed. During an interview via phone on 11/03/2023 at 11:09 a.m., RP W said she was going to call the HHSC hotline number this afternoon with concerns related to Resident #1's DNR status she requested at the hospital but was not completed and thought the nurses notification of the resident receiving CPR was not appropriate. RP W said she was the medical and financial power of attorney for Resident #1 and on 10/31/2023 she was notified by the nurse via phone that the resident was returned to the facility without a DNR being in place and the nurse did CPR on Resident #1, called 911, and the ambulance went to pick him up. RP W said the nurse told her the resident was really gray and was probably still deceased after RP W said the DNR process was initiated at the hospital. RP W said it upset her the nurse said it was okay CPR was initiated because he was probably still deceased . RP W said they intubated him at the hospital, removed it the next day and RP W said she had to watch him expire. RP W said Resident #1 expired on 11/1/23 at 7:14 p.m. after the hospital withdrew care around 1:30 p.m. RP W said the nurse called her on 10/31/2023 at 8:58 p.m. and notified her Resident #1 was laying over the bed, his foot was hanging off the bed and was unresponsive. RP W said there was no mention of assist bars and had never been notified of the potential risks with using assist bars and had not been asked for consent for bed rails. RP W said she last visited Resident #1 a couple of months ago and was aware he had assist bars on his bed. During an interview via phone on 11/03/2023 at 11:27 a.m., the hospital physician said Resident #1 was in the hospital in the beginning of October and was discharged on 10/31/2023 to facility and returned to the hospital on a ventilator. RP W requested to withdraw care and he expired and felt it was a shame he did not pass peacefully and had to get intubated. During an interview on 11/03/2023 at 11:47 a.m., the DON said she did not know when assist bars were installed on Resident #1's bed but Resident #1 had the assist bars since she has been employed at the facility in June 2023. During an interview and record review on 11/3/2023 at 10:50 a.m., the Administrator said there was a form to check for bed safety under maintenance electronic records and it showed checklists were overdue sometimes when it was completed early. The Administrator said he was able to log in and access the maintenance electronic records system at any time and Maintenance notified him if there were any Maintenance concerns. Review of maintenance electronic record logs, dated 11/02/2023, reflected bed safety checks were overdue by one month for all residents. During an interview on 11/03/2023 at 11:51 a.m., the DON said the facility did not obtain consent for bed rails to complete bed safety risk assessments for all residents with assist rails prior to Resident #1's incident on 10/31/2023 because they were not aware they assist bars were considered to be bed rails and he was not assessed for risk of entrapment prior to bed rail install. The DON said there is a list with residents that use assist bars for nursing staff to refer to and she confirmed with corporate that assist bars were not treated as bed rails prior to Reisdent #1's incident. The DON said nursing staff would now be assessing and obtaining consent for use of assist bars since it was important for residents and representatives to be aware of associated risks such as entrapment. The DON said following Resident #1's self-reported incident on 10/31/2023, interventions would be put in place for assist bars that include bed assessments and addressing assist bars in care plans. She said the IDT team is responsible for ensuring the resident have orders for assist rails. Review of facility policy, titled Bed Safety, revised November 2023, revealed the following: Policy Statement Our facility shall strive to provide a safe sleeping environment for the resident. Policy Interpretation and Implementation 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. 2. To try to prevent deaths/injuries from the beds and related equipment (including the timeframe, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: . 9. When using assist rails for any reason, the staff shall take measures to reduce related risks. 10. Assist rails shall not be used as protective restraints. This facility is a restraint free environment, 11. The staff shall report to the director of nursing and the administrator any deaths, serious illness and/or injuries resulting from a problem associated with a bed and related equipment including the bed frame, bed side rails, and mattresses. The administrator shall ensure that reports are made to the Food and Drug Administration or other appropriate agencies, in accordance with pertinent laws and regulations including the Safe Medical Devices Act. Review of facility policy, titled Abuse Prevention Program, revised December 2016, revealed the following: Policy Statement Our residents have the right to be free from abuse, neglect . This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation As part of the resident abuse prevention, the administration will: . 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. 4. Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. 9. Establish and implement a QAPI review and analysis of abuse incidents; and implement changes to prevent future occurrences . Review of facility policy, titled Abuse Investigation and Reporting, revised July 2017, revealed: Policy Interpretation and Implementation Role of the Administrator . 5. The administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. Review of facility policy, titled Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures, revised December 2006, revealed: Policy Statement The Administrator is responsible for the overall coordination and implementation of our facility's abuse prevention program policies and procedures. Policy Interpretation and Implementation 1. The Administrator has the overall responsibility for the coordination and implementation of our facility's abuse prevention program policies and procedures. 2. The Administrator has the authority to delegate coordination and implementation of various components of these policies and procedures to other individuals within the facility. These may include: a. The Director of Nursing Services; b. The Director of Social Services; c. The Director of Staff Development; d. Tho Director of Risk Management; e. The Assistant Administrator; f. The Medical Director; g. The Quality Assessment and Assurance Committee· and h. Other staff members as determined by the Administrator. Review of facility policy, titled Investigating Injuries, revised December 2016, revealed: Policy Statement The administrator will ensure that all injuries are investigated. Policy Interpretation and Implementation 1. The director of nursing services or a designee will assess all injuries and document clinical findings in the clinical record. 2. If an incident/accident is suspected, a nurse or nurse supervisor will complete a facility-approved accident/incident form. The form will be disseminated to the appropriate individuals, for example the administrator and director of nursing services. 3. Injury of unknown source is defined as an injury that meets both of the following conditions: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of: (1) the extent of the injury; or (2) the location of the injury ( .the injury is located in an area not generally vulnerable to trauma); or (3) the number of injuries observed at one particular point in time; or (4) the incidence of injuries over time. 4. Documentation shall include information relevant to risk factors and conditions that could ca[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to implement policies and procedures that prohibit and prevent physical restraints of residents for 1 (Resident #1) of 31 residents reviewed for physical restraints. The facility failed to inform Resident #1 or their representative of the risks associated with use of assist bars, care plan for risks associated with assist bars, obtain consent for the use of assist bars, and obtain physician orders for use of assist bars, and implement interventions following identified entrapment incident from assist bars. Resident #1 was found by LVN A on the floor in his room with his left arm caught between the assist bar and air mattress on 09/24/2023 and had no interventions to address risk of entrapment following incident. Resident #1 was found by CNA A in his room with his left arm, head and neck between the assist bar and air mattress and his legs on the floor mat on 10/31/2023 and CPR was initiated. Resident #1 expired at the hospital on [DATE] following intubation and responsible party withdraw of care. An IJ was identified on 11/03/2023. The IJ template was provided to the facility on [DATE] at 3:40 p.m. While the IJ was removed on 11/05/2023, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for entrapment with serious injury or death. Findings included: 1. Record review of Resident #1's face sheet, dated 11/02/2023, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included repeated falls, epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors), congenital stenosis (abnormal spinal narrowing present at birth) and obstruction of esophagus, age related physical debility, spastic hemiplegia (muscles on one side of the body being in a constant state of contraction) affecting left nondominant side, dizziness and giddiness, and general muscle wasting and atrophy. Record review of Physician Orders dated 11/02/2023, reflected Resident #1 had no orders for assist bars. Record review of Resident #1 ' s Progress Notes, between August 2023 through October 2023, reflected Resident #1 had a fall on 09/24/2023 in his room and was found by LVN B with his left arm between the assist bar and bed. There were no bed safety assessments for use of assist bars on or after 9/24/2023. The resident had an additional fall in his room on 10/31/2023 and was found unresponsive by CNA A and appeared grey in color with his left arm, head and neck between the assist bar and air mattress with his legs on the floor mat and CPR was immediately initiated by RN R at 6:50 p.m. EMS was called and arrived at 6:58 p.m. and Resident #1 was transferred to the hospital. Record review of Resident #1 ' s care plan, revised 08/11/2023, reflected the resident had a history of falls and seizures with interventions to include: review information on past falls, attempt to determine cause of falls, record possible root causes, alter/remove any potential causes, if possible, educate resident/family/caregivers/IDT about causes, safety reminders and what to do if fall occurs, attempt to find the resident triggers for falls, attempting to self-toilet (initiate trial toileting program); confusion in the evening (encourage distraction activities in the evening); the resident needs a safe environment with even floors free from spills and/or clutter, and the bed in low position at night. The care plan did not address assist bars or risks associated with use of assist bars. Record review of Resident #1's most recent significant change in status MDS, dated [DATE], reflected he had a Brief Interview for Mental Status score of 03, which indicated severe cognitive impairment. Resident #1's functional status reflected he was non-ambulatory and required a two person assist for bed mobility. Record review of Resident #1's assessments between September 2023 and October 2023, reflected there were no bed safety assessments completed. Record review of incident report log between September 1, 2023 through November 3, 2023 reflected Resident #1 had a history of falls on 09/02/2023 at 11:13 p.m., three falls on 09/21/23 at 1:00 p.m., 1:30 p.m., and 1:45 p.m., one fall on 09/22/2023 at 10:45 p.m., one fall on 09/24/2023 at 2:00 p.m., one fall on 10/01/2023 at 1:45 a.m., two falls on 10/5/2023 at 2:25 a.m. and 7:45 p.m., one fall on 10/10/2023 at 12:45 a.m., two falls on 10/15/2023 at 10:42 a.m. and 7:00 p.m. and 10/16/2023 at 5:52 p.m. Record review of incident report written by LVN A, dated 09/24/2023 at 2:00 p.m., reflected Resident #1 was found sitting on the floor with back up against the bed with his left arm between the mattress and railing. Bed was in lowest position. Resident was able to move his arm from between the bed and railing with assistance Resident #1 had a small abrasion to his left elbow and front right knee, resident was assisted to bed with gait belt, and resident was unable to give a description. Record review of incident report written by RN R, dated 10/31/2023, reflected Resident #1 was found at approximately 6:50 p.m. by CNA A and noted to be .sitting on buttocks on floor with left arm around right-side bed rail and left side of neck/head lodged between mattress and side rail. Resident was grey in color, warm to touch and faint right-side jugular pul[s]e noted. [CNA A] notified this RN (RN R) that was across the hall at medication cart on resident's hall. I (RN R) entered room and [CNA A] and I placed resident on the floor and began CPR. [LVN T] called 911 and printed paperwork for EMS. I began chest compressions for 5 cycles while [CNA A] assisted with the [bag valve mask] and we swapped out after 5 cycles. [CNA B] joined in rotation. [AED] applied after 1 cycle of CPR. Directions followed and no shock advised. When paramedics arrived Resident O2 sats [were] 95% on O2 2L [nasal canula]. Contacted emergency contact [RP W], [MD], and [DON] in report incident. Record review of, undated, witness statement by CNA A reflected he was taking residents out for their evening smoke break when a resident notified him that Resident #1 was on the floor. He immediately went to the room and saw Resident #1's head almost stuck in the side rail and he looked pale. CNA A reported he notified RN R that Resident #1 looked pale and was nonresponsive and RN R stayed in the room while he ran to get the crash cart. RN R and CNA A proceeded to do chest compressions until the paramedics arrived. Record review of, undated, witness statement, did not document a name and date, reflected at approximately 6:50 p.m., CNA A noted resident sitting on buttocks on the floor with left arm around right-side rail and left side of head/neck lodged between mattress and side rail, resident was grey in color, warm to touch, and faint jugular pulse noted to right side. CNA A notified RN R that was at medication cart across from residents' room. The witness statement reflected: I (RN R) entered room and [CNA A] and I (RN R) placed resident on floor and began CPR. [LVN B] called 911 and printed paperwork for EMS. I began chest compressions for 5 cycles and [CNA A] used [bag valve mask] and we swapped after 5 cycles CNA B joined in the rotation 3 cycles in CPR performed 10 min. [AED] was applied after 1 cycle of CPR. Directions followed and no shock advised. When paramedics arrived resident O2 sat (oxygen saturation) was 95% on O2 2L (Liters) NC (Nasal Cannula). [RP W] contacted notified at [phone number] at 8:58 p.m. by RN A. She stated he is not DNR and is in the process of being placed on Hospice. Record review of Resident #1's hospital records, dated 11/01/2023, reflected he presented to the ER post cardiac arrest, and he was found after he slid out of his bed with his head in the bed rail. When nursing found the resident, he did not have a pulse, CPR was initiated, upon EMS arrival patient had a pulse, and intubation was attempted but unable to place in a definitive airway. A transfer to other acute facility was ordered for a higher level of care due to acute exacerbation (worsening of airway function). Record review of the Provider Investigation Report, dated 11/02/2023, reflected the following: .At approximately 1850 [6:50 p.m.] [CNA A] noted resident sitting on buttocks on floor with left arm around right side bed rail and left side of neck/head between mattress and side rail with chin resting on side rail. and Resident was noted to be sitting on buttocks on floor with left arm around right side of bed rail and left side rail and left side of neck/head lodged between mattress and side rail .resident was grey in color, warm to touch and faint right side jugular pulse noted . Provider Response [RN A] with the assistance of [CNA A] placed resident on the floor and began CPR while the other duty called 911 and prepared papers for transfer. RN began chest compressions for 5 cycles while CNA assisted with the [bag valve mask] bag and they swapped out after 5 cycles. [CNA B] assisted in the rotation. AED applied after first cycle fo CPR with no shock advised. When EMS on scene resident had O2 saturation of 95% on NC (nasal cannula) [at] 2/L O2 and a heartbeat was present. Resident placed on stretcher and transported out of facility. Resident emergency contact and attending physician notified of incident and transport by EMS. Investigation Summary Staff present/assisting with the emergency were interviewed. Statements have been and are being obtained. Staff member who was first on scene (CNA A) demonstrated exactly what he saw when entering resident room. The demonstration reveals the left arm between assist rail and mattress with head resting upon left shoulder and chin resident on the side rail, the neck free from pressure/compression. Upon interview [CNA A] indicated that when he entered the resident room the resident's neck/airway was not compromised and his chin was resting on the side rail .his shoulder blades and head were pressed in the area, but his neck was totally free. [CNA A] stated they did lower the rail or deflate the mattress but rather lifted the resident carefully up and over, then onto the ground. [CNA A] stated, 'his neck was free .his oxygen tubing was not on his face but on the ground.' [Resident #1's] bed, mattress, and assist rails were evaluated by maintenance to ensure no malfunction and proper fit to meet FDA standards, all equipment was in good working order and the distance measured between the air mattress and the assist rail was 2.5 inches. All statements were reviewed/analyzed as well as the re-enactment demonstration and it is not confirmed that the resident suffered strangulation in the assist rail as there was no pressure noted to be on the resident's airway. It is not confirmed that neglect occurred as the resident had no more than an hour before the last interaction with staff and this incident. Resident has a history of self-transfer attempts and all measures to prevent injury were in place (bed in lowest position, fall mats at bedside, door left open, and call light within reach.) Record review of witness statement by CNA B, dated 11/3/2023 at 1:03 p.m., reflected the following: During my first rounds after clocking in I saw [Resident #1] in his bed awake, head of bed elevated, feet down. [Resident #1's] feet were hanging off the end of the bed, the sheets were on the floor. Resident repositioned in bed, new bedding on resident. Head elevated and feet elevated. Call light in reach. I continued on my rounds making my way down the halls. I was on the therapy hall when I hea[r]d [RN A] yell out HELP! Call 911 and got the crash cart. She and [CNA A] were looking for the [bag valve mask] bag, gave it to [RN A] and [CNA A] and I were rotating compressions. Doing roughly 2-3 each then switching. CPR for approximately 5-10 minutes before EMS arrived. They took over compressions, changed out the AED and got vital[s]. He was breathing when EMS arrived. During an interview on 11/02/2023 at 9:28 a.m., the Administrator and the DON said Maintenance was responsible for the bed and assist bar installation and maintenance. The Administrator said he was not sure who last saw Resident #1 but it had been within the hour and the resident was initially at the hospital for altered mental status and failure to thrive before he returned from the hospital a couple hours prior to incident. The Administrator said Resident #1 returned on 10/31/2023 at 4:00 p.m. and the incident occurred at 6:50 p.m. The Administrator and the DON said CNA A found him with his left arm, head and neck between the assist bar and air mattress with his legs on the floor. The Administrator and the DON said RN A assessed the resident and immediately began CPR, AED device was obtained, and resident was a full code when he returned from the hospital even though his RP had requested a DNR at the hospital, there was not a DNR in place prior to return. The Administrator and DON said EMS arrived and he was transported to the hospital and was anticipated to return on hospice. The Administrator and DON said the roommate was in the room but was unable to communicate and was not interviewable and RP W and attending physician were notified of the incident. During an observation on 11/02/2023 at 10:00 a.m., Resident #31, roommate of Resident #1, was lying in bed free from apparent injury and appeared confused. Resident #31 did not respond to questions and the room appeared free from hazards and no assist bars were installed to beds in the room. During an interview on 11/02/2023 at 11:36 AM, Maintenance said she had been employed at the facility for 3 years and was responsible for installation and maintenance of assist bars on beds. Maintenance said she did not know what happened to Resident #1 but was asked to measure the distance between the mattress to the grab bar. Maintenance said she took both bed rails and put them on the bed to see how far the mattress was able to move and measured the spacing to be 2 and a half inches. She was not aware of a facility policy for gap requirements between assist bars and beds and did not know where to find the information if needed but was asked to measure by the DON and corporate office. Maintenance said all beds and assist bars were the same except for geriatric beds. Maintenance said she had never measured the distance between the air mattress and bed before and 11/1/2023 was the first time she had measured it because she was not aware of the space requirements. Maintenance said she never noticed any gaps between the mattress and assist bar and did not recall specifically looking for that and no similar incidents of entrapment had happened that she was aware of. Maintenance said if there was a staff member requesting an assist bar, they grabbed them off the bed and there was a key that went to it and that was how it was assembled to the bed. Maintenance said maintenance requests were placed in the maintenance book at the nursing station and computer system. All staff looked at the beds every day and did not have a routine safety check scheduled and there were no issues with assist bars and the air mattress was sufficient size for Resident #1. Maintenance said she was not aware of the potential risks assist bars posed to residents. There was usually a physician's order to install assist bars and she was notified by the nurse and assist bars were in good condition and secure. Maintenance said it was important for assist bars to be installed appropriately because residents could have a fall and not be able to get up by themselves and couple pose a risk of entrapment. Maintenance said all residents were physically able to use assist bars. During an interview and record review on 11/02/2023 at 12:15 p.m., Maintenance provided an assist bar and observed attached warning label which indicated risk of entrapment to include. WARNING/SAFETY ALERT .Powered air mattress surfaces may pose a risk of entrapment. Prior to use, ensure the therapeutic benefits outweigh the risk of entrapment. Maintenance said there were residents with air mattresses and assist bars still at the facility and that the provided assist bar and manual, titled [Company L] Instructions For Use Service Manual, was used on all beds. Record review of Company L manual for the bed reflected optional assist bar installation instructions, on pg.17, indicating Power air mattress surfaces may pose a risk of entrapment. Prior to use, ensure the therapeutic benefits outweigh the risk of entrapment. During an interview via phone on 11/02/2023 at 2:00 p.m., RN R said she had been employed at the facility for a month and worked on Resident #1's hall. RN R said she was provided training on neglect via in-services but had not received training on assist bars following incident since she had not returned to work following the incident on 10/31/2023 with Resident #1. RN R said Resident #1 was discharged from the hospital on [DATE] and she tried to obtain orders for feeding since the hospital did not send any orders with him and she knew previously that he was a tube feeder. RN R said Resident #1 fell constantly and he was being monitored constantly by staff and had him up at the nurses station the majority of time at night. RN R said she obtained feeding orders and put everything on the medication cart to go down the hall and administered a pain pill to his neighbor when she walked past his room and he was laying in his room at baseline. RN R said she entered the neighbors room and administered medication then crossed the hall to administer medication to another resident when CNA A notified her she needed to come to Resident #1's room. RN R said when she walked in Resident 31's room he was on the right side of the bed and his left arm was wedged on the other side between the mattress and the arm rail and his head was lodged there on his left side. RN R said he was sitting on his buttocks with his legs out straight, arm in the rail and the corner of his head an inch in on the throat area with his head turned to the right. RN R said she removed the resident from the rail and administered 2 cycles fo CPR when his color started to come back. RN A said the other nurse on duty called 911 and paramedics arrived 8 minutes later. RN R said the defibrillator was placed on the resident and CPR continued. RN R said his oxygen saturations were at 95% and he came with oxygen from the hospital but when he left the facility to be transferred to the ER he was breathing on his own. RN R said the ambulance remained outside for 30 to 45 minutes before leaving and she assumed they were placing an IV line. RN R said she called the hospital and was informed he was intubated. RN A said she last saw the resident at 6:45 p.m. on 10/31/2023 when she told him she would be back to feed him. RN R said she notified the attending physician and representative of incident. RN R said Resident #1 had a history of rolling out of the bed while he was asleep, and she had not noticed any gaps between the assist bar and air mattress prior to this incident and she did not pay much attention to gap space requirements. RN R said it was important risks of assist bars were reviewed with residents to obtain consent and inform about the risks of entrapment if installed on air mattress beds. RN R said she had not returned to work since the incident and was supposed to have a meeting today about everything and she believed it was rescheduled for next week. RN R said she was not sure what space was allowed between the assist bar and air mattress, but she thought there should be no space in that zone. RN R said Maintenance was responsible for installing bed rails and all staff were responsible for checking bed safety on a routine basis, but RN R was not sure who did the assessment for assist bars and if she was responsible for completing and would have to consult with the DON. RN A said the IDT team was usually responsible for reviewing and obtaining orders for assist bars upon admission RN R said Resident #1 was able to physically use the assist bars for bed mobility. During an interview on 11/2/2023 at 3:58 p.m., the Administrator said a QAPI meeting was not conducted following the reported incident with Resident #1 and the meeting would be around the middle of November 2023. During an interview via phone on 11/02/2023 at 5:17 p.m., CNA A said on 10/31/2023 he found Resident #1 with his left arm, head and neck between the assist bar and mattress and the gap between the assist bar and bed appeared to be approximately 2 to 3 centimeters wide. CNA A said he last saw Resident #1 about 10 minutes prior to incident when he went in the room to remove his food tray and reported Resident #1 was at baseline. CNA A said he never saw him get stuck like that before in the assist bar. CNA A said he worked at the facility since the incident and had not received training on bed safety, and he felt training would be helpful. CNA A said he believed the gap amount allowed between the mattress and assist bar was 2 inches or 2 and half inches. CNA A said assist bars posed a risk of entrapment to all residents who were bed bound and on-air mattresses such as Resident #3 and it would be important for residents or representatives to know the risk of assist bars to include potential entrapment so they would have the knowledge needed to make the appropriate decision for use. CNA A said the nurses were responsible for ensuring bed safety but all staff could look at the beds and notify the nurse with any concerns. CNA A said he felt residents used the assist bars appropriately and only had a concern for resident with air mattresses and assist bars installed to bed that were not cognitively intact. CNA A said he did not know if residents were being notified of the potential risks with using assist bars and it would be the nurse's responsibility or the IDT team to do so upon admission. CNA A said he was not sure when the resident had his assist bars installed but CNA A had been at the facility for 2 years and believed the resident had always had them on his bed. During an interview via phone on 11/03/2023 at 11:09 a.m., RP W said she was going to call the HHSC hotline number this afternoon with concerns related to Resident #1's DNR status she requested at the hospital but was not completed and thought the nurses notification of the resident receiving CPR was not appropriate. RP W said she was the medical and financial power of attorney for Resident #1 and on 10/31/2023 she was notified by the nurse via phone that the resident was returned to the facility without a DNR being in place and the nurse did CPR on Resident #1, called 911, and the ambulance went to pick him up. RP W said the nurse told her the resident was really gray and was probably still deceased after RP W said the DNR process was initiated at the hospital. RP W said it upset her the nurse said it was okay CPR was initiated because he was probably still deceased . RP W said they intubated him at the hospital, removed it the next day and RP W said she had to watch him expire. RP W said Resident #1 expired on 11/1/23 at 7:14 p.m. after the hospital withdrew care around 1:30 p.m. RP W said the nurse called her on 10/31/2023 at 8:58 p.m. and notified her Resident #1 was laying over the bed, his foot was hanging off the bed and was unresponsive. RP W said there was no mention of assist bars and had never been notified of the potential risks with using assist bars and had not been asked for consent for bed rails. RP W said she last visited Resident #1 a couple of months ago and was aware he had assist bars on his bed. During an interview via phone on 11/03/2023 at 11:27 a.m., the hospital physician said Resident #1 was in the hospital in the beginning of October and was discharged on 10/31/2023 to facility and returned to the hospital on a ventilator. RP W requested to withdraw care and he expired and felt it was a shame he did not pass peacefully and had to get intubated. During an interview on 11/03/2023 at 11:47 a.m., the DON said she did not know when assist bars were installed on Resident #1's bed but Resident #1 had the assist bars since she has been employed at the facility in June 2023. During an interview and record review on 11/3/2023 at 10:50 a.m., the Administrator said there was a form to check for bed safety under maintenance electronic records and it showed checklists were overdue sometimes when it was completed early. The Administrator said he was able to log in and access the maintenance electronic records system at any time and Maintenance notified him if there were any Maintenance concerns. Review of maintenance electronic record logs, dated 11/02/2023, reflected bed safety checks were overdue by one month for all residents. During an interview on 11/03/2023 at 11:51 a.m., the DON said the facility did not obtain consent for bed rails to complete bed safety risk assessments for all residents with assist rails prior to Resident #1's incident on 10/31/2023 because they were not aware they assist bars were considered to be bed rails and he was not assessed for risk of entrapment prior to bed rail install. The DON said there is a list with residents that use assist bars for nursing staff to refer to and she confirmed with corporate that assist bars were not treated as bed rails prior to Reisdent #1's incident. The DON said nursing staff would now be assessing and obtaining consent for use of assist bars since it was important for residents and representatives to be aware of associated risks such as entrapment. The DON said following Resident #1's self-reported incident on 10/31/2023, interventions would be put in place for assist bars that include bed assessments and addressing assist bars in care plans. She said the IDT team is responsible for ensuring the resident have orders for assist rails. An Immediate Jeopardy (IJ) situation was identified on 11/03/2023. While the IJ was removed on 11/05/2023, the facility remained out of compliance at a scope of pattern with actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. Review of facility policy, titled Bed Safety, revised November 2023, revealed the following: Policy Statement Our facility shall strive to provide a safe sleeping environment for the resident. Policy Interpretation and Implementation 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. 2. To try to prevent deaths/injuries from the beds and related equipment (including the timeframe, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: . 9. When using assist rails for any reason, the staff shall take measures to reduce related risks. 10. Assist rails shall not be used as protective restraints. This facility is a restraint free environment, 11. The staff shall report to the director of nursing and the administrator any deaths, serious illness and/or injuries resulting from a problem associated with a bed and related equipment including the bed frame, bed side rails, and mattresses. The administrator shall ensure that reports are made to the Food and Drug Administration or other appropriate agencies, in accordance with pertinent laws and regulations including the Safe Medical Devices Act. Review of facility policy, titled Abuse Prevention Program, revised December 2016, revealed the following: Policy Statement Our residents have the right to be free from abuse, neglect . This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation As part of the resident abuse prevention, the administration will: . 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. 4. Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. 9. Establish and implement a QAPI review and analysis of abuse incidents; and implement changes to prevent future occurrences . Review of facility policy, titled Abuse Investigation and Reporting, revised July 2017, revealed: Policy Interpretation and Implementation Role of the Administrator . 5. The administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. Review of facility policy, titled Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures, revised December 2006, revealed: Policy Statement The Administrator is responsible for the overall coordination and implementation of our facility's abuse prevention program policies and procedures. Policy Interpretation and Implementation 1. The Administrator has the overall responsibility for the coordination and implementation of our facility's abuse prevention program policies and procedures. 2. The Administrator has the authority to delegate coordination and implementation of various components of these policies and procedures to other individuals within the facility. These may include: a. The Director of Nursing Services; b. The Director of Social Services; c. The Director of Staff Development; d. Tho Director of Risk Management; e. The Assistant Administrator; f. The Medical Director; g. The Quality Assessment and Assurance Committee· and h. Other staff members as determined by the Administrator. Review of facility policy, titled Investigating Injuries, revised December 2016, revealed: Policy Statement The administrator will ensure that all injuries are investigated. Policy Interpretation and Implementation 1. The director of nursing services or a designee will assess all injuries and document clinical findings in the clinical record. 2. If an incident/accident is suspected, a nurse or nurse supervisor will complete a facility-approved accident/incident form. The form will be disseminated to the appropriate individuals, for example the administrator and director of nursing services. 3. Injury of unknown source is defined as an injury that meets both of the following conditions: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of: (1) the extent of the injury; or (2) the location of the injury ( .the injury is located in an area not generally[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure bedrails were assessed for the risk of entrapment of residents prior to installation, and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 9 of 31 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, and Resident #9) reviewed for bed rails. 1. The facility failed to inform Resident #1, Resident#2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, and Resident #9 or their representative of the risks associated with the use of assist bars. 2. The facility failed to care plan for risks associated with assist bars, obtain consent for the use of assist bars, and obtain physician orders for use of assist bars. 3. The facility failed to ensure Resident #1 did not have his left arm caught between the assist bar and air mattress on [DATE]. 4. The facility failed to ensure Resident #1's left arm, head and neck were not between the assist bar and air mattress with his legs on the floor mat on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern with actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for entrapment with serious injury or death. Findings include: 1. Record review of Resident #1's face sheet, dated [DATE], reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included repeated falls, epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors), congenital stenosis (abnormal spinal narrowing present at birth) and obstruction of esophagus, age related physical debility, spastic hemiplegia (muscles on one side of the body being in a constant state of contraction) affecting left nondominant side, dizziness and giddiness, and general muscle wasting and atrophy. Record review of Physician Orders dated [DATE], reflected Resident #1 had no orders for assist bars. Record review of Resident #1 ' s Progress Notes, between [DATE] through [DATE], reflected Resident #1 had a fall on [DATE] in his room and was found by LVN B with his left arm between the assist bar and bed. There were no bed safety assessments for use of assist bars on or after [DATE]. The resident had an additional fall in his room on [DATE] and was found unresponsive by CNA A and appeared grey in color with his left arm, head and neck between the assist bar and air mattress with his legs on the floor mat and CPR was immediately initiated by RN R at 6:50 p.m. EMS was called and arrived at 6:58 p.m. and Resident #1 was transferred to the hospital. Record review of Resident #1 ' s care plan, revised [DATE], reflected the resident had a history of falls and seizures with interventions to include: review information on past falls, attempt to determine cause of falls, record possible root causes, alter/remove any potential causes, if possible, educate resident/family/caregivers/IDT about causes, safety reminders and what to do if fall occurs, attempt to find the resident triggers for falls, attempting to self-toilet (initiate trial toileting program); confusion in the evening (encourage distraction activities in the evening); the resident needs a safe environment with even floors free from spills and/or clutter, and the bed in low position at night. The care plan did not address assist bars or risks associated with use of assist bars. Record review of Resident #1's most recent significant change in status MDS, dated [DATE], reflected he had a Brief Interview for Mental Status score of 03, which indicated severe cognitive impairment. Resident #1's functional status reflected he was non-ambulatory and required a two person assist for bed mobility. Record review of Resident #1's assessments between [DATE] and [DATE], reflected there were no bed safety assessments completed. Record review of incident report log between [DATE] through [DATE] reflected Resident #1 had a history of falls on [DATE] at 11:13 p.m., three falls on [DATE] at 1:00 p.m., 1:30 p.m., and 1:45 p.m., one fall on [DATE] at 10:45 p.m., one fall on [DATE] at 2:00 p.m., one fall on [DATE] at 1:45 a.m., two falls on [DATE] at 2:25 a.m. and 7:45 p.m., one fall on [DATE] at 12:45 a.m., two falls on [DATE] at 10:42 a.m. and 7:00 p.m. and [DATE] at 5:52 p.m. Record review of incident report written by LVN A, dated [DATE] at 2:00 p.m., reflected Resident #1 was found sitting on the floor with back up against the bed with his left arm between the mattress and railing. Bed was in lowest position. Resident was able to move his arm from between the bed and railing with assistance Resident #1 had a small abrasion to his left elbow and front right knee, resident was assisted to bed with gait belt, and resident was unable to give a description. Record review of incident report written by RN R, dated [DATE], reflected Resident #1 was found at approximately 6:50 p.m. by CNA A and noted to be .sitting on buttocks on floor with left arm around right-side bed rail and left side of neck/head lodged between mattress and side rail. Resident was grey in color, warm to touch and faint right-side jugular pul[s]e noted. [CNA A] notified this RN (RN R) that was across the hall at medication cart on resident's hall. I (RN R) entered room and [CNA A] and I placed resident on the floor and began CPR. [LVN T] called 911 and printed paperwork for EMS. I began chest compressions for 5 cycles while [CNA A] assisted with the [bag valve mask] and we swapped out after 5 cycles. [CNA B] joined in rotation. [AED] applied after 1 cycle of CPR. Directions followed and no shock advised. When paramedics arrived Resident O2 sats [were] 95% on O2 2L [nasal canula]. Contacted emergency contact [RP W], [MD], and [DON] in report incident. Record review of, undated, witness statement by CNA A reflected he was taking residents out for their evening smoke break when a resident notified him that Resident #1 was on the floor. He immediately went to the room and saw Resident #1's head almost stuck in the side rail and he looked pale. CNA A reported he notified RN R that Resident #1 looked pale and was nonresponsive and RN R stayed in the room while he ran to get the crash cart. RN R and CNA A proceeded to do chest compressions until the paramedics arrived. Record review of, undated, witness statement, did not document a name and date, reflected at approximately 6:50 p.m., CNA A noted resident sitting on buttocks on the floor with left arm around right-side rail and left side of head/neck lodged between mattress and side rail, resident was grey in color, warm to touch, and faint jugular pulse noted to right side. CNA A notified RN R that was at medication cart across from residents' room. The witness statement reflected: I (RN R) entered room and [CNA A] and I (RN R) placed resident on floor and began CPR. [LVN B] called 911 and printed paperwork for EMS. I began chest compressions for 5 cycles and [CNA A] used [bag valve mask] and we swapped after 5 cycles CNA B joined in the rotation 3 cycles in CPR performed 10 min. [AED] was applied after 1 cycle of CPR. Directions followed and no shock advised. When paramedics arrived resident O2 sat (oxygen saturation) was 95% on O2 2L (Liters) NC (Nasal Cannula). [RP W] contacted notified at [phone number] at 8:58 p.m. by RN A. She stated he is not DNR and is in the process of being placed on Hospice. Record review of Resident #1's hospital records, dated [DATE], reflected he presented to the ER post cardiac arrest, and he was found after he slid out of his bed with his head in the bed rail. When nursing found the resident, he did not have a pulse, CPR was initiated, upon EMS arrival patient had a pulse, and intubation was attempted but unable to place in a definitive airway. A transfer to other acute facility was ordered for a higher level of care due to acute exacerbation (worsening of airway function). Record review of the Provider Investigation Report, dated [DATE], reflected the following: .At approximately 1850 [6:50 p.m.] [CNA A] noted resident sitting on buttocks on floor with left arm around right side bed rail and left side of neck/head between mattress and side rail with chin resting on side rail. and Resident was noted to be sitting on buttocks on floor with left arm around right side of bed rail and left side rail and left side of neck/head lodged between mattress and side rail .resident was grey in color, warm to touch and faint right side jugular pulse noted . Provider Response [RN A] with the assistance of [CNA A] placed resident on the floor and began CPR while the other duty called 911 and prepared papers for transfer. RN began chest compressions for 5 cycles while CNA assisted with the [bag valve mask] bag and they swapped out after 5 cycles. [CNA B] assisted in the rotation. AED applied after first cycle fo CPR with no shock advised. When EMS on scene resident had O2 saturation of 95% on NC (nasal cannula) [at] 2/L O2 and a heartbeat was present. Resident placed on stretcher and transported out of facility. Resident emergency contact and attending physician notified of incident and transport by EMS. Investigation Summary Staff present/assisting with the emergency were interviewed. Statements have been and are being obtained. Staff member who was first on scene (CNA A) demonstrated exactly what he saw when entering resident room. The demonstration reveals the left arm between assist rail and mattress with head resting upon left shoulder and chin resident on the side rail, the neck free from pressure/compression. Upon interview [CNA A] indicated that when he entered the resident room the resident's neck/airway was not compromised and his chin was resting on the side rail .his shoulder blades and head were pressed in the area, but his neck was totally free. [CNA A] stated they did lower the rail or deflate the mattress but rather lifted the resident carefully up and over, then onto the ground. [CNA A] stated, 'his neck was free .his oxygen tubing was not on his face but on the ground.' [Resident #1's] bed, mattress, and assist rails were evaluated by maintenance to ensure no malfunction and proper fit to meet FDA standards, all equipment was in good working order and the distance measured between the air mattress and the assist rail was 2.5 inches. All statements were reviewed/analyzed as well as the re-enactment demonstration and it is not confirmed that the resident suffered strangulation in the assist rail as there was no pressure noted to be on the resident's airway. It is not confirmed that neglect occurred as the resident had no more than an hour before the last interaction with staff and this incident. Resident has a history of self-transfer attempts and all measures to prevent injury were in place (bed in lowest position, fall mats at bedside, door left open, and call light within reach.) Record review of witness statement by CNA B, dated [DATE] at 1:03 p.m., reflected the following: During my first rounds after clocking in I saw [Resident #1] in his bed awake, head of bed elevated, feet down. [Resident #1's] feet were hanging off the end of the bed, the sheets were on the floor. Resident repositioned in bed, new bedding on resident. Head elevated and feet elevated. Call light in reach. I continued on my rounds making my way down the halls. I was on the therapy hall when I hea[r]d [RN A] yell out HELP! Call 911 and got the crash cart. She and [CNA A] were looking for the [bag valve mask] bag, gave it to [RN A] and [CNA A] and I were rotating compressions. Doing roughly 2-3 each then switching. CPR for approximately 5-10 minutes before EMS arrived. They took over compressions, changed out the AED and got vital[s]. He was breathing when EMS arrived. During an interview on [DATE] at 9:28 a.m., the Administrator and the DON said Maintenance was responsible for the bed and assist bar installation and maintenance. The Administrator said he was not sure who last saw Resident #1 but it had been within the hour and the resident was initially at the hospital for altered mental status and failure to thrive before he returned from the hospital a couple hours prior to incident. The Administrator said Resident #1 returned on [DATE] at 4:00 p.m. and the incident occurred at 6:50 p.m. The Administrator and the DON said CNA A found him with his left arm, head and neck between the assist bar and air mattress with his legs on the floor. The Administrator and the DON said RN A assessed the resident and immediately began CPR, AED device was obtained, and resident was a full code when he returned from the hospital even though his RP had requested a DNR at the hospital, there was not a DNR in place prior to return. The Administrator and DON said EMS arrived and he was transported to the hospital and was anticipated to return on hospice. The Administrator and DON said the roommate was in the room but was unable to communicate and was not interviewable and RP W and attending physician were notified of the incident. During an observation on [DATE] at 10:00 a.m., Resident #31, roommate of Resident #1, was lying in bed free from apparent injury and appeared confused. Resident #31 did not respond to questions and the room appeared free from hazards and no assist bars were installed to beds in the room. During an interview, observation, and record review on [DATE] at 10:20 a.m., Resident #8 said she was recently admitted to the facility within 90 days for physical therapy. Resident #8 had assist bars installed to left and right side of her bed and said she used the bed rails on her bed to pull herself up and she had no concerns with them. Resident #8 said the facility had not reviewed the risks associated with using assist bars or obtained her consent to have them and the bed had them installed when she arrived at the facility. 2. Record review of Resident #8's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #8 had diagnoses which included muscle weakness (generalized), lack of coordination, post cholecystectomy syndrome (persistence of biliary colic or right upper quadrant abdominal pain with a variety of gastrointestinal symptoms similar to those in patients with cholecystitis prior to cholecystectomy), acute kidney failure, morbid (severe) obesity due to excess calories, acute cholecystitis (inflammation of gallbladder), and heart failure. Record review of Resident #8's chart reflected the care plan did not address bed rails/assist bars and there were no physician orders or assessments for assist bars located in resident's chart. Record review of Resident #8's MDS, dated [DATE], reflected she had a Brief Interview for Mental Status score of 13, which indicated intact cognition. Resident #8 had a functional status of 02 for lying to sitting on back of bed, which indicated she required substantial/maximal assistance for bed mobility. Record review of Resident #8's care plan, revised [DATE], reflected the resident had a risk of ADL self-performance deficit and limitations to physical mobility related to muscle weakness, lack of coordination and morbid obesity with interventions to include a two person assist for bed mobility. Assist bar intervention for mobility had an initiation date of [DATE]. There were no interventions in place for use of assist bars prior to [DATE]. Record review of Resident #8's progress note, dated [DATE], reflected: Resident assessed for the use of assist rails. Resident has impaired mobility r/t weakness and decreased strength secondary to morbid obesity, morbidity weakness, and other abnormalities of gait. Assist rails are used during incontinent care to assist in pulling [herself] from side to side and to provide leverage when transferring from the bed. Resident is able to verbalize the reason for the assist rail placement. Direct caregiver interviewed to verify resident use of side rails. Resident does not have a history of falling from the bed or seizure disorder. Resident may have assist rails in place. Progress notes reflected no risks were reviewed when using assist bar and consent was not obtained. Record review of Resident #8's physician orders reflected there were no orders in place for assist bars until [DATE] at 6:00 p.m., post State Surveyor intervention. 3. Record review of Resident #3's face sheet, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included: malignant neoplasm (cancerous tumors) of unspecified ovary, anemia, recurrent depressive disorders, atherosclerotic heart disease (clogged artery) of native coronary artery, acute embolism (blood clot), thrombosis (formation or presence of blood clot) of left popliteal vein, pleural effusion (fluid in space surrounding lung), perforation of intestine, muscle weakness (generalized), surgical aftercare following surgery on the digestive system, and colostomy status. Record review of Resident #3's admission MDS, dated [DATE], reflected she had a Brief Interview for Mental Status score of 15, which indicated intact cognition and a functional status of limited assistance with one person assist for bed mobility. Record review of Resident #3's care plan, revised [DATE], reflected she had a problem of ADL self-performance deficit related to cancer and interventions included use of assist bar and one person assist for bed mobility. There were no additional interventions for assist bar prior to [DATE] at 6:00 p.m. Record review of Resident #3's physician orders reflected assist bar orders had a start date of [DATE] at 6:00 p.m. During an observation on [DATE] at 10:28 a.m., Resident #3 appeared to be resting in bed with air mattress and assist bar in place. 4. During an interview, observation, and record review on [DATE] at 10:30 a.m., Resident #9 said the facility had never reviewed the risks of using bed assist rails installed to her bed and did not know there were any risks. Resident #9 was lying in her bed with head of bed elevated and appeared well groomed, pleasant, and in no distress, and bed assist bars were installed on both sides to bed. Record review of Resident #9's face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #9 had diagnoses which included: type 2 diabetes with diabetic neuropathic arthropathy (bone and joint changes that occur secondary to loss of sensation), age related osteoporosis (bone disease that develops when bone mineral density and bone mass decreases), lack of coordination, insomnia (sleep disorder), cognitive communication deficit, recurrent depressive disorders, atrial fibrillation (irregular heart rhythm), abnormalities of gait and mobility, age related cognitive decline, visual field defects, heart failure, muscle wasting and atrophy to right and left lower legs, generalized muscle weakness, difficulty in walking, unsteadiness on feet, malaise (general sense of being unwell), and age related physical debility. Record review of Resident #9's quarterly MDS, dated [DATE], reflected she had a Brief Interview for Mental Status score of 15, which indicated intact cognition. Resident #9's functional status was 05, setup or clean-up assistance required for resident who can independently complete activity for lying to sitting and rolling in bed. Record review of Resident #9's care plan, revised [DATE], reflected she had a risk of ADL self-care performance deficit and limitations in physical mobility related to fatigue/malaise/weakness with intervention to include use of assist bar for mobility with a date initiated of [DATE]. There were no assist bar interventions implemented prior to [DATE]. Record review of Resident #9's physician orders reflected an order for her assist bar was received on [DATE] at 6:00 p.m., following State Surveyor intervention. Record review of Resident #9's progress notes on [DATE] during POR monitoring, written by LVN C, dated [DATE] at 10:31 a.m., reflected telephone consent for assist bars were obtained by the representative and the risks for using bed rails were explained to include: risks of strangling, suffocating, bodily injury, or death. Record review of Resident #9's progress notes written by the DON, dated [DATE] at 7:36 p.m., reflected the resident was assessed for the use of assist rails with noted impaired mobility related to weakness and decreased strength secondary to muscle wasting and atrophy, and osteoporosis. Assist rails were used during incontinent care to assist in pulling [herself] from side to side and to provide leverage when transferring from the bed and the resident was able to verbalize the reason for the assist rail placement. The CNA's verify resident use of side rails and the resident did not have a history of falling from the bed or any seizure disorder. Resident #9 may have assist rails in place. During an interview and observation on [DATE] at 10:30 AM, Resident #9 said the facility never reviewed the risks of using her bed assist bars or obtained consent prior to install and did not know there were any risks involved. Resident #9 had bed assist bars installed on both left and right sides to the bed. During an interview on [DATE] at 11:36 AM, Maintenance said she had been employed at the facility for 3 years and was responsible for installation and maintenance of assist bars on beds. Maintenance said she did not know what happened to Resident #1 but was asked to measure the distance between the mattress to the grab bar. Maintenance said she took both bed rails and put them on the bed to see how far the mattress was able to move and measured the spacing to be 2 and a half inches. She was not aware of a facility policy for gap requirements between assist bars and beds and did not know where to find the information if needed but was asked to measure by the DON and corporate office. Maintenance said all beds and assist bars were the same except for geriatric beds. Maintenance said she had never measured the distance between the air mattress and bed before and [DATE] was the first time she had measured it because she was not aware of the space requirements. Maintenance said she never noticed any gaps between the mattress and assist bar and did not recall specifically looking for that and no similar incidents of entrapment had happened that she was aware of. Maintenance said if there was a staff member requesting an assist bar, they grabbed them off the bed and there was a key that went to it and that was how it was assembled to the bed. Maintenance said maintenance requests were placed in the maintenance book at the nursing station and computer system. All staff looked at the beds every day and did not have a routine safety check scheduled and there were no issues with assist bars and the air mattress was sufficient size for Resident #1. Maintenance said she was not aware of the potential risks assist bars posed to residents. There was usually a physician's order to install assist bars and she was notified by the nurse and assist bars were in good condition and secure. Maintenance said it was important for assist bars to be installed appropriately because residents could have a fall and not be able to get up by themselves and couple pose a risk of entrapment. Maintenance said all residents were physically able to use assist bars. During an interview and record review on [DATE] at 12:15 p.m., Maintenance provided an assist bar and observed attached warning label which indicated risk of entrapment to include. WARNING/SAFETY ALERT .Powered air mattress surfaces may pose a risk of entrapment. Prior to use, ensure the therapeutic benefits outweigh the risk of entrapment. Maintenance said there were residents with air mattresses and assist bars still at the facility and that the provided assist bar and manual, titled [Company L] Instructions For Use Service Manual, was used on all beds. Record review of Company L manual for the bed reflected optional assist bar installation instructions, on pg.17, indicating Power air mattress surfaces may pose a risk of entrapment. Prior to use, ensure the therapeutic benefits outweigh the risk of entrapment. During an interview and record review on [DATE] at 1:17 p.m., the DON said the ADON assisted her with questioning all CNA staff on assist bar knowledge to assess resident needs for rails. The DON said there were additional residents utilizing assist bars with air mattresses and provided a list. There were 28 residents with assist bars and currently five residents with assist bars and air mattresses at the facility to include Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6. The DON said they kept air mattresses on the bed when residents were admitted with a wound and assist bar risks were reviewed prior to placing the mattress. The DON said it would either be herself or the floor nurses who were responsible for assist rail assessments and obtaining consent and informing their representative. The DON said staff were required to obtain consent for assist bars on admission or prior to install. Maintenance was responsible for installing bed rails and all nursing staff checked rails daily when in the room with the resident and would notify Maintenance verbally and responds when needed if there were any concerns. The DON said any gap between assist bars and mattresses over 2 and half or three inches would be out of compliance per facility policy. Record review of facility policy, dated [DATE] titled, Guidance for Industry and FDA Staff - Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, included a table, located on pg. 21, for Zone 3 Between rail and mattress with a dimensional limit of less than 120 mm (4 ¾ inches) for the area between the inside surface of the rail and a compressed mattress. The DON said it was important to obtain consent and assess bed safety with assist bars installed since they posed a potential risk of entrapment. The DON said all staff had not been trained on the bed safety in-services and was waiting on the opposite rotation night shift and those staff had not returned to work since the incident occurred with Resident #1 on [DATE]. The DON said bed safety assessments may be available in the electronic health record under the evaluations tab, but she was not sure. 5. Record review of Resident #2's face sheet, dated [DATE], reflected she was a [AGE] year-old female admitted on [DATE] with diagnoses including malaise (general sense of being unwell), fatigue, morbid (severe) obesity due to excess calories, generalized muscle weakness, repeated falls, age related physical debility, need for assistance with personal care, and muscle wasting and atrophy. Record review of Resident #2's quarterly MDS, dated [DATE], reflected she had a Brief Interview for Mental Status Score of 15, indicating she was cognitively intact and a functional status of 04 for bed mobility indicating she required supervision or touching assistance. Record review of Resident #2's physician orders reflected there were no orders for assist bars prior to [DATE] at 6:00 p.m. Record review of Resident #2's care plan, revised [DATE], revealed assist bars were not addressed prior to [DATE]. The care plan addressed assist bars on [DATE] following State Surveyor intervention. Record review of Resident #2's progress notes, dated between [DATE] through [DATE], reflected a bed assessment was completed on [DATE] and consent was obtained by Resident #2 for assist bars on [DATE] at 10:56 a.m. following State Surveyor intervention. 6. Record Review of Resident #4's facesheet reflected she was a [AGE] year-old female admitted on [DATE] with diagnoses including pressure ulcer of sacral region, muscle weakness, morbid (severe) obesity due to excess calories, lack of coordination, dizziness and giddiness, and abnormalities of gait and mobility. Record review of Resident #4's 5 day MDS, dated [DATE], reflected she had a Brief Interview for Mental Status score of 14, indicating she was cognitively intact and had a functional status of 01 indicating she was dependent for bed mobility. Record review of Resident #4's care plan, revised [DATE], reflected assist bars were not addressed prior to [DATE]. Record review of Resident #4's physician orders reflect there no orders for assist bars prior to [DATE] at 6:00 p.m. Record review of Resident #4's progress notes, dated between [DATE] through [DATE], reflected she was assessed for assist bars on [DATE] and consent was obtained for assist bars on [DATE] following State Surveyor intervention. 7. Record Review of Resident #5's facesheet reflected he was a [AGE] year-old male admitted on [DATE] with diagnoses including facial weakness following other cerebrovascular disease, dysphagia (difficulty in swallowing) following cerebrovascular disease, psychosis, major depressive disorder, psychosis (severe mental condition), muscle wasting and atrophy, generalized muscle weakness, abnormalities fo gait and mobility, lack of coordination, need for assistance with personal care, and history of falling. Record review of Resident #5's quarterly MDS, dated [DATE], reflected he had a Brief Interview for Mental Status score of 07, indicating severe cognitive impairment and had a functional status of extensive assist for bed mobilty and required a two person assist. Record review of Resident #5's care plan, revised [DATE], reflected assist bars were not addressed prior to [DATE]. Record review of Resident #5's physician orders reflect there no orders for assist bars prior to [DATE] at 6:00 p.m. Record review of Resident #5's progress notes, dated between [DATE] through [DATE], reflected he was assessed for assist bars on [DATE] and consent was obtained for assist bars on [DATE] and [DATE]. 8. Record review of Resident #6's facesheet reflected she was a [AGE] year-old female admitted on [DATE] with diagnoses including fracture of right lower leg, muscle weakness, and initial encounter for fall. Record review of Resident #6's admission MDS, dated [DATE], reflected she had a Brief Interview for Mental Status score of 15, indicating she was cognitively intact and a functional status of 03 indicating partial/moderate assistance for bed mobility. Record review of Resident #6's care plan, revised [DATE], reflected assist bars were not addressed prior to [DATE]. Record review of Resident #6's physician orders, reflected there were no orders for assist bars prior to [DATE] at 6:00 p.m. Record review of Resident #6's progress notes, dated [DATE], reflected a bed assessment was completed and consent obtained on [DATE] and there were no assessments for bed rails prior to [DATE]. 9. Record review of Resident #7's facesheet reflected she was a [AGE] year-old female admitted on [DATE] with diagnoses including infection and inflammatory reaction due to internal right hip prosthesis (artificial body part), difficulty in walking, pain in right shoulder, muscle wasting and atrophy, restless leg syndrome, cataract, osteoarthritis, major depressive disorder, age-related physical debility, lack of coordination, abnormalities of gait and mobility, encounter for other surgical aftercare, insomnia (sleep disorder), morbid (severe) obesity due to excess calories, and diaphragm[TRUNCATED]