**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to ensure each resident was free from physical restraints. Resident #48 was physically restrained by the facility, causing psychosocial harm. This was true for one (1) of one (1) residents reviewed for physical restraints during the long term care survey process. Resident identifier: #48. Facility census: 51. Findings included: a) Resident #48 At approximately 12:00 PM on 08/12/24, during review of the resident matrix (resident census and conditions of residents) provided by the facility, it was determined the facility had Resident #48 marked as being in physical restraints. Upon review of Resident #48's record, it was determined the resident was in a geri chair with a hard lap tray across it, preventing the resident from standing. The order for the restraint reads as follows: When OOB (Out of Bed): GERICHAIR BILAT HIPSTERS & LAP TRAY FOR SAFETY. CHECK RES (Resident) Q30 MIN (Every 30 minutes) FOR PROPER POSITIONING OF RES & LAP TRAY Q2 HOURS & PRN FOR EXERCISE, REST, TOILETING & HYGIENE NEEDS. At approximately 1:30 PM on 08/12/24, an interview was conducted with Licensed Practical Nurse (LPN) #103 regarding the geri chair and lap tray for Resident #48. LPN #103, regarding the lap tray, stated, I've been here since he first got here. When he got here he would walk around all the time, but he had some falls so they put him in the chair and put the tray on it so he couldn't get up and walk. LPN #103 was asked if Resident #48 was able to release the lap tray from the chair on command, in the event of an emergency, to which she stated No, he can't release it. But he can probably yell out if he needs help (Multiple attempts were made to communicate with Resident #48 during the survey process, however, Resident #48 never spoke, nor yelled during the survey). At this time, Resident #48 was observed trying to stand up out of the geri chair, but was unable to due to the lap tray. Resident #48's right leg started to bounce up and down, anxiously, when he was unsuccessful in standing. Seconds later, Resident #48 attempted to stand again, which was unsuccessful. After a second unsuccessful attempt at standing up, Resident #48's right leg bounced up and down harder, and at a faster pace. This continued for approximately 30 seconds and Resident #48 fell asleep in the chair. During further record review at approximately 3:00 PM on 08/12/24, it was noted the facility entered the following note, completed by the Director of Nursing (DON) into Resident #48's record on 7/30/24: Assessment completed regarding continuing the need for lap tray. After assessing resident we will continue to utilize the lap tray due to increase in fall risk in the past. Resident did have a decline in health in [DATE] and the lap tray was discontinued on 12/6/23. The resident began walking again without assistance and having increased falls. It was decided we would re-order a soft lap buddy on 1/4/24. Resident still continued to walk and have increased falls. The lap tray was re-ordered on 1/8/24. Resident has had the following orders in the past due to increased falls. Low bed, removing mattress from the low bed with another mat beside (as resident tends to get out of bed and crawl on the floors,) helmet, hipsters, soft lap buddy. Nothing has been successful. The order will continue for the lap tray and to release q2h prn for periods of rest, activies [sic], hygeine [sic], brief changes, or to lay down in bed. MPOA is aware of the lap [NAME] [sic] and in agreement for continued use. The Pre-restraint assessment completed by the facility, attached to the progress note, revealed the facility did not assess Resident #48 for the use of a wheelchair, walker, chair alarm, cane, or many other forms of restraint alternatives, before putting him into a geri chair with a lap tray, as evidenced by the section titled Restraint Alternatives on the assessment. The options given are low bed, wheelchair, cushion, chair alarm, wedges, non-slip grip socks, walker, pillow, cane, other. Marked with an X in the section are low bed, non-slip grip socks, and other. The final section of the pre-restraint assessment titled Results have the following options: None, chemical restraint, physical restraint. The box reading None is marked with an X while chemical restraint and physical restraint are not marked. A call was placed to the wife of Resident #48, who is the Medical Power of Attorney (MPOA), to determine whether she was aware of the use of the lap tray, due to the note stating the MPOA was aware of the lap buddy, and not the lap tray, however, the call was not successful. Despite the note dated 7/30/24 stating the resident required the geri chair and lap tray as a restraint for safety due to increased falls, a preliminary viewing of the incident report provided by the facility, from December 2023, through August 2024, the resident had five (5) incidents from 12/15/23 through 7/16/24, one of which was a result of a shower chair breaking as the resident was on the way to be bathed. Of the remaining four, it was unclear which ones, if any, the resident was ambulating before falling, as all the incidents were noted as unwitnessed. At approximately 9:15 AM on 08/13/24, this surveyor entered the dining room on unit 3-C of the facility, where Resident #48 was parked in the geri chair. Resident #48 was noted to be in the geri chair, with the lap tray down, and his pants were visibly soiled/wet in the groin area. At approximately 9:21 AM, Resident #48 attempted to stand up from the geri chair but was unable to due to the lap tray. At this time, Resident #48's right leg began to bounce up and down, anxiously. The resident attempted to stand again, unsuccessfully, at which time his right leg began to bounce up and down at a faster pace. Resident #48 attempted to stand a third time and was unsuccessful, at which time his leg bounced up and down faster. At this time, Resident #48 attempted to stand up from the geri chair a fourth time, again, unsuccessfully. At this time, the resident's right leg was bouncing, furiously, up and down, along with his left hand. The resident seemed visibly agitated and anxious at this time. The resident eventually calmed down after approximately five (5) minutes and fell asleep in his chair. At approximately 9:37 AM, Nurse Aide (NA) #8 entered the dining room and began speaking with another resident was falling asleep in his wheelchair. NA #8 asked the resident if he wanted to go back to his room to go to sleep, at which time she took the resident back to his room. NA #8 did not interact with Resident #48, nor check on him for proper positioning of himself or the lap tray, nor did she notice he was visibly soiled. NA #8 entered the dining room again at approximately 9:40 AM and removed a clothing protector from breakfast from a female resident, then removed the resident from the dining room. NA #8 did not interact with Resident #48 at this time, nor did she notice he was visibly soiled. At approximately 9:46 AM, NA #8 escorted a new resident into the dining room and placed them at the table to the direct right of Resident #48. At this time, there was no interaction with Resident #48 to check positioning of him, the lap tray, or to notice he was visibly soiled. At approximately 9:47 AM, NA #57 entered the dining room with another new resident, placed the at the table next to Resident #48. NA #57 did not notice Resident #48 was soiled, nor did they check for proper positioning of the resident or lap tray. At approximately 9:49 AM, Recreation Specialist (RS) #69, entered the dining room to escort residents to an activity taking place at the time. As RS #69 approached Resident #48, she stated Oh, he's wet, at which point, she backed away from Resident #48, gathered other residents, and left the dining room. RS #69 did not ask Resident #48 if he needed assistance, nor did she check to see if the lap tray, or Resident #48, was properly positioned. At approximately 9:51 AM, NA #8 entered the dining room again. NA #8 walked over to a resident sitting beside Resident #48, spoke with resident, turned around, used the hand sanitizer dispenser, and left the dining room. NA #8 did not check on Resident #48, despite him being visibly soiled, for proper positioning of him or the lap tray. At approximately 10:06 AM, Resident #48 attempted to stand up from the geri chair, however, he was unsuccessful due to the lap tray. At this time, the resident started bouncing his legs up and down, anxiously. The resident attempted to reposition himself in the geri chair at this time. Resident's legs now are bouncing faster and harder. Resident #48 attempted to stand out of the chair one more time, unsuccessfully. At this time, the resident's legs were bouncing faster. At approximately 10:15 AM, NA #57 entered the dining room and asked two other residents if they wanted to go to the social and listen to some music. The residents stated they did, at which time, she escorted them past Resident #48, out the door and to the activity room. NA #57 did not check on Resident #48 during this trip to the dining room, leaving him still, visibly soiled, and the positioning of him and the lap tray in question. At this time, Resident #48 remained the only resident in the dining room. At approximately 10:21 AM, NA #8 and NA #57 entered the dining room. NA #8 stated He's wet. NAs began to escort resident out of the dining room, at which point, this surveyor asked them if RS #69 had come to inform them Resident #48 was soiled after she left the dining room at approximately 9:49 AM. Both NAs stated no. At approximately 10:30 AM, NA #8 and #57 were observed brining Resident #48 out into the hallway from his room, standing him up out of the chair, and assisting him with walking approximately 15 to 20 feet before sitting him back in the chair. Resident #48 was observed in the chair the rest of the day. Review of the facility's policy on physical restraints states the opportunity for motion and exercise is provided for a period of not less than ten (10) minutes during each two (2) hours in which restraints are employed. Resident #48 was exercised for approximately 30 to 40 seconds. At approximately 10:45 AM on 08/13/24, the Administrator of the facility was notified of Resident #48 being visibly soiled at approximately 9:15 AM, RS #69 entering the dining room and stating Oh, he's wet and leaving, without alerting staff, resulting in Resident #48 not being changed until approximately 10:21 AM. The administrator asked how long the resident was sitting in the dining room soiled. This surveyor stated, From about 9:15 AM until about 10:21 AM when the aides came to get him. However, he was already wet, so he may have been way for a longer period of time. At this time, the administrator stated the facility would report and investigate the claim of neglect. The facility completed its investigation and substantiated the allegation of neglect due to RS #69 stating she forgot to notify anyone of Resident #48's needs. At approximately 10:00 AM on 08/14/24, Resident #48 was observed attempting to stand up from his geri chair. The attempt was unsuccessful and the resident began to bounce his left leg up and down at a fast pace. The resident seemed anxious and agitated. At approximately 10:02 AM, Resident #48 attempted to rise out of the geri chair for a second time. Unsuccessful, the resident started to bounce his leg at a faster pace. The resident seemed more agitated and anxious. At approximately 10:04 AM, Resident #48 attempted, again, to stand from the geri chair. The resident was unsuccessful and seemed to become more agitated and anxious, bouncing his leg up and down ferociously. The resident eventually stopped trying to get up and began to stare off. A reasonable person standard was applied to this situation because Resident #48 is not able to verbalize how not being able to stand was making him feel. However, he was showing outward signs of agitation as evidenced by his leg bouncing up and down and it becoming faster after each attempt to stand up. A reasonable person would feel agitation and frustration if restrained and not able to stand and walk freely Further record review revealed Resident #48 has orders for a weighted blanket while in bed and a concave mattress, due to increased falls from bed. At approximately 12:00 PM on 08/14/24, an interview was conducted with the DON, in which she was asked to supply incident reports pertaining to the falls suffered by Resident #48 and how they led to him being physically restrained in the geri chair. The DON stated the resident had a number of falls and the facility was concerned about his safety. The DON was asked if the facility ever considered less restrictive measures before they restrained Resident #48 in the geri chair, such as a wheelchair. The DON stated We didn't believe a wheelchair was appropriate for him, so no, I don't believe we did evaluate him for one, but I would have to check to make sure. The DON stated she did not believe the resident could propel a wheelchair now, stating He probably could have before, but not now. Review of the Minimum Data Set (MDS) Assessments For Resident #48 revealed the following: For the MDS dated [DATE], Section G0300 reveals the resident was Steady at all times while walking. The resident was independently walking distances of ten (10) feet on uneven surfaces and with picking up objects. The MDS showed the resident required partial to moderate assistance, or supervision for Activities of Daily Living (ADLs) The MDS also revealed the resident received no restorative services at this time. The MDS indicated the resident exhibited wandering behaviors every day. After the initial order for the physical restraint on 06/16/24, the MDS dated [DATE] revealed the resident remained independent with the same tasks as in the MDS in May 2023. The MDS states the resident exhibits wandering behaviors daily. In a significant change MDS, dated [DATE], the resident was not noted to have any impairment of lower or upper extremity. However, walking was no longer attempted, due to a medical or safety concern, and the resident was now totally dependent for all ADLs. The resident still, according to the MDS, exhibited wandering behavior daily. Each MDS was submitted following the significant change in August 2023, up to and including the annual MDS dated [DATE], now shows the resident completely dependent for all ADLs, walking not being attempted due to a medical or safety concerning, and exhibiting wandering behavior daily, despite being restrained in the geri chair with a lap tray. At approximately 1:00 PM on 08/14/24, an interview was conducted the the MDS Coordinator and the DON. The MDS coordinator was asked about the resident exhibiting wandering behavior daily if he was in the chair. The MDS Coordinator stated When they release him from the chair he will stand up and walk. He will stand up and walk if he isn't watched. The DON was asked if the resident was able to walk if he would be able to propel a wheelchair on his own, despite her saying she did not feel he could in an earlier interview. The DON stated Some days he can walk and some days he can't. We thought he would slide out of a wheelchair if we put him in one. The DON and MDS Coordinator both stated Resident #48 was able to ambulate independently up until the point of being ordered the geri chair with the lap tray. The DON confirmed at this time the facility did not assess Resident #48 for a wheelchair due to them believing he would slide out of it. Review of the Treatment Administration Record (TAR) for Resident #48 reveals the following order: When OOB (Out of Bed): GERICHAIR BILAT HIPSTERS & LAP TRAY FOR SAFETY. CHECK RES (Resident) Q30 MIN (Every 30 minutes) FOR PROPER POSITIONING OF RES & LAP TRAY Q2 HOURS & PRN FOR EXERCISE, REST, TOILETING & HYGIENE NEEDS. Upon review of the TAR for May, June, July, and August 2024, there are no initials or signatures on the TAR to indicate the resident was ever released from the restraint every two hours. At approximately 2:19 PM on 08/14/24, the DON stated the facility did not have a signed consent from Resident #48's MPOA for the use of the restraint. The DON was asked about the progress note dated 7/30/24, in which it states the MPOA is aware of the use of the lap buddy and agrees with its usage, and if the MPOA knows of the lap buddy or the more restrictive lap tray. The DON states the MPOA is aware of the lap tray but is unable to provide any documentation to support. The DON states the MPOA is hard to get a hold of by phone and has never visited the resident since he came to the facility, and is unable to provide any proof of consent, other than the note stating the MPOA is aware. The DON was then asked about the TAR, and being unable to verify the resident was released from the restraints as ordered. The DON stated That is just on there as an FYI, no one signs off on it. There are nurses notes stating he was released from the restraints. When asked how the facility verifies the resident was released from the restraints every two hours, since no one signs off on the TAR, the DON stated I don't guess I really have a way, other than the nurses notes are in there. At this time, the DON and this surveyor reviewed the nurses notes in the system from May through August 2024. This review revealed no notes mentioning the resident was released from the restraints every two hours as required. When asked if she would confirm there were no signatures or nursing notes to indicate the resident was removed from the restraints, the DON stated I confirm there's nothing there but I don't agree with it. The DON supplied the incident reports pertaining to falls for Resident #48 from April of 2023 through August 2024. Upon review of an incident report dated 07/10/24, it was noted a bruise was observed by NA #8 while changing the resident. The bruise was noted to be on the left leg of the resident and to be the same height and size as the armrest on the geri chair. The incident reports revealed the following: 04/19/23- Presumed fall. Resident lying in floor with table overturned. 04/27/23- Resident lying on bathroom/shower floor resting his head on his hands. No injuries or redness. Resident stated he didn't fall. 04/30/23- Resident ambulating in hallway, and fell on his left arm and slid down wall to floor. Brief noted around resident's knees. Brief fell to resident's knees, may have contributed to fall. 05/06/23- Resident fell on left shoulder and hip while turning in front of a door. 06/13/23- Resident observed in floor of dining room with another resident's wheelchair flipped forward. 06/15/23- Resident found by NA, head pointing downward in the floor. Legs and feet pointing upward draped across dining room chair. Lap tray was ordered on 06/16/23. The DON stated in the interview the resident used to be in the military and would crawl underneath his roommates bed, thinking he was working on it, and that's how staff would sometimes find him. The exact number of falls of the resident falling while ambulating compared to the resident rolling out of bed are unknown.