Adams County Manor

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure staff provided timely bathing and hair washing assistance for dependent residents. This affected one (Resident #8) of the three residents reviewed for activities of daily living (ADL) assistance. The facility census was 69 residents. Findings include:Review of the medical record for Resident #8 revealed an admission date of 11/27/25 with diagnoses including acute kidney failure, adult failure to thrive, and depression. Review of the Minimum Data Set (MDS) assessment for Resident #8 dated 11/27/25 revealed the resident was cognitively intact. Review of the care plan for Resident #8 dated 12/11/25 revealed the resident was at risk for a self-care deficit with bathing, dressing, and feeding. Interventions included the following: encourage the resident to participate in planning day to day care, evaluate the resident's ability to perform self-care, minimize environmental stimuli, provide assistance with ADLs as needed. Review of the shower task list for Resident #8 initiated 11/27/25 revealed the resident was scheduled to receive showers on night shift on Sundays and Thursdays. Review of the shower documentation for Resident #8 dated 02/26/26 through 03/25/26 revealed the resident received showers on 03/06/26 and 03/22/26. There were no additional showers documented during the 30-day time frame. Observation on 03/24/26 at 8:45 A.M. of Resident #8 revealed the resident's hair was greasy and appeared unwashed. Interview on 03/24/26 at 8:46 A.M. with Resident #8 confirmed she preferred to have a shower or bed bath at least twice a week and to have her hair washed on those days. Resident #8 confirmed she had not had her hair washed in weeks and did not receive a shower or bed bath at least twice a week per her preference. Observation on 03/26/26 at 9:05 A.M. of Resident #8 revealed the resident's hair was greasy and appeared unwashed. Interview on 03/26/26 at 9:06 A.M. with Resident #8 confirmed she had still not received a shower or had her hair washed. Interview 03/26/26 at 10:50 A.M. with the Director of Nursing (DON) confirmed residents should receive showers and hair washing per their scheduled preference and staff were to document the showers and care in the resident's medical record. The DON confirmed Resident #8 was documented to have received two showers or bed baths from 02/26/26 through 03/25/26 and was not documented to have refused any care. Review of the facility policy titled Supporting Activities of Daily Living revised March 2018 revealed residents who were unable to carry out ADLs independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. This deficiency represents noncompliance investigated under Complaint Number 2647177.

Based on observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure resident shower floors were maintained in good repair. This affected four (Residents #10, #11, #35, and #38) of the 24 residents sampled for showers. The facility census was 69 residentsFindings include: Observation on 03/23/26 at 1:16 P.M. revealed the shower floor in Resident #10 and Resident #11's bathroom had a large amount of water pooled on top of the tiles. Several floor tiles were cracked, grout was missing between multiple tiles, and the surface of the tiles was uneven. Observation on 03/26/26 at 9:00 A.M. revealed the shower floor in the room of Resident #35 and Resident #38's bathroom had multiple broken and/or missing tiles, and the surface of the tiles was uneven. Interview on 03/26/26 at 9:01 A.M with Resident #35 confirmed multiple tiles on the shower floor were missing or broken and the water did not drain well. Interview on 03/26/26 at 9:10 A.M with Certified Nursing Assistant (CNA) #562 confirmed the shower floors in Resident #10, #11, #35, and #38's bathrooms had missing, cracked, and broken tiles and confirmed the water did not drain correctly from the showers causing water to pool on the shower floors after the residents' showers. Review of the facility policy titled Homelike Environment undated revealed the facility encouraged the personalization and comfort of a home-like environment. This deficiency represents noncompliance investigated under Complaint Number 2647177.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facilities policy review, the facility failed to follow hand sanitation infection control practices during meal tray delivery. This had the potential to affect seven rooms of residents (Residents in rooms #204, #205, #209, #210, #105, #106 and #110). The facility total census was 64.
Findings include:
Observation on 03/20/24 during lunch meal tray delivery, between 11:40 A.M. and 11:54 A.M., revealed State Tested Nurse Aide, (STNA) # 118 delivered the lunch meal tray to Resident room [ROOM NUMBER]. STNA #118 hands touched resident personal items on the overbed table to make room for the meal tray. The STNA #118 removed lids from the bowls of foods, touched the surface of the overbed table and touched the surface of the resident bed. STNA #118 exited Resident room [ROOM NUMBER] room past a wall mounted hand sanitizer dispensing station and a handwashing sink without sanitizing her hands. STNA #118 returned to the food delivery cart, touched the cart surface, touched her hair and delivered Resident room [ROOM NUMBER] meal tray. STNA #118 was observed to remove resident personal items from the overbed table, remove food container lids and touch the overbed table surface. STNA #118 exited Resident room [ROOM NUMBER] room, past a wall mounted hand sanitizer dispensing station and a handwashing sink, without sanitizing her hands.
Observation on 03/20/24 between 11:40 A.M. and 11:54 A.M., revealed STNA #107 entered Resident Rooms #209, arranged personal items on the bedside stand, removed food bowl lids and touched the bed surface. STNA #107 exited Resident room [ROOM NUMBER] room, past a wall mounted hand sanitizer dispensing station and a handwashing sink, without sanitizing her hands. STNA #107 obtained and delivered Resident room [ROOM NUMBER] meal tray without performing hand sanitation between Resident room [ROOM NUMBER] and Resident room [ROOM NUMBER] meal tray deliveries.
Observation on 03/20/24 during lunch meal tray delivery, between 11:50 A.M. and 12:01 P.M., revealed STNA #170 delivered the lunch meal tray to Resident room [ROOM NUMBER]. STNA #170 was observed to remove personal items from the overbed table, remove food bowl lids, assisted resident positioning, and touched the bed linens. The STNA #170 exited the room without hand sanitation, including washing or use of hand sanitizer. STNA #170 obtained Resident room [ROOM NUMBER] meal tray and delivered the meal tray. STNA #170 touched personal resident objects on the overbed table. STNA #170 did not perform hand sanitizing when leaving the room. STNA #170 obtained and delivered Resident room [ROOM NUMBER] meal tray with hand sanitizing from meal tray delivery of Resident room [ROOM NUMBER].
Interview on 03/20/24 at 11:48 A.M., STNA #118 verified she had not performed hand sanitation between meal tray delivery of Resident Rooms #204 and Resident room [ROOM NUMBER]. STNA #118 stated hand sanitation should be performed between every meal tray delivery. STNA #118 verified there were hand washing sinks and wall mounted hand sanitizing solution dispensers in every resident room.
Interview on 03/20/24 at 11:49 A.M., STNA #107 verified she had not performed hand sanitation between meal deliveries of Resident room [ROOM NUMBER] and Resident room [ROOM NUMBER]. STNA #107 stated sometimes the nurse aides forget to perform hand sanitizing between each meal tray delivery.
Interview on 03/20/24 at 12:12 P.M., STNA #170 verified she had not performed hand sanitizing between meal tray delivery between Resident Rooms #105, Resident room [ROOM NUMBER] and Resident room [ROOM NUMBER]. STNA #170 stated she was unsure how often hand sanitation should occur between meal tray deliveries.
Interview on 03/21/24 at 10:39 A.M. the Director of Nursing, (DON) verified hand sanitizing should occur after handling a resident's belongings. The DON verified hand sanitizer solution and hand washing sinks were in each resident room for staff to perform hand sanitizing after meal tray delivery and prior to delivery of the next resident's meal delivery.
Review of the facility policy, titled, Infection Control Hand Hygiene, undated, revealed hand hygiene is in reference to utilization of alcohol-based products and or hand washing with soap and water. Use of hand hygiene is required before and after every resident contact including touching a resident, handling the resident's belongings, and after touching the face or hair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interview, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) was completed accurately and following the additional of a new mental health diagnosis. This affected three residents (#6, #39, and #53) out of the four residents whose PASRR's were reviewed during the annual survey. The facility census was 64.
Findings include:
1. Record review for Resident #6 revealed the resident was admitted to the facility on [DATE] and had diagnoses including dementia without behavioral disturbance, psychotic disturbance, and mood disturbance.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/20/24, revealed this resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 05 out of 15.
Further record review for Resident #6 revealed the resident had a new mental health diagnosis of psychosis added on 01/04/21 while residing in the facility. No new PASRR was completed following the addition of a new mental health diagnosis.
Interview with the Administrator on 03/20/24 at 11:30 A.M. confirmed a new PASRR was not completed following the addition of the diagnosis of psychosis on 01/04/21.
2. Record review of Resident #39 revealed the resident was admitted to the facility on [DATE] and readmitted [DATE]. Diagnoses for Resident #39 included diagnosis of depression listed on 10/10/23, psychosis listed on 05/05/22, and anxiety disorder listed on 06/08/21.
Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed, the resident had impaired cognition and was receiving medications Duloxetine HCL 20 milligrams (mg) at bedtime for depression and Buspirone HCL 10 mg two times a day for anxiety disorder.
Review of Resident #39 PASARR , dated 09/13/22, did not include the diagnoses of psychosis and depression.
Interview on 03/20/24 at 2:30 P.M. the Administrator verified Resident #39 PASARR, dated 09/13/22, was inaccurate as it did not include the resident's diagnoses of psychosis and depression.
3. Record review of Resident #53 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #53 included dementia, bipolar disorder and depression.
Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE], revealed the resident had severely impaired cognition and was receiving medications Olanzapine 2.5 mg two times a day for bipolar disorder, Divalproex sodium 125 mg for bipolar disorder and Citalopram hydrobromide 10 mg for depression.
Review of Resident #53 PASARR , dated 02/02/22, did not include the diagnoses of bipolar disorder and dementia.
Interview on 03/20/24 at 2:30 P.M., the Administrator verified Resident #53 PASARR, dated 02/02/22 was inaccurate as it did not include the resident's diagnoses of bipolar disorder and dementia.

Based on record review, observation, and staff interview, the facility failed to ensure the resident's call lights were functioning. This affected three (Resident #09, #16 and #18) of 24 residents reviewed for call lights. The facility census was 64 residents.
Findings include:
1. Review of the medical record of Resident #09 revealed an admission date of 03/31/21. Diagnoses included dementia without behavioral disturbance, type 2 diabetes mellitus, muscle weakness, and bipolar disorder. Review of the Medicare five-day Minimum Data Set (MDS) assessment, dated 06/23/21, revealed the resident had impaired cognition and required extensive assistance of two staff for bed mobility, transfers, and toileting.
Review of the medical record for Resident #18 revealed an admission date of 09/17/20. Diagnoses included cerebrovascular disease, acute ischemic heart disease, dementia with behavioral disturbance, and cerebral infarction (stroke). Review of the comprehensive MDS assessment, dated 04/14/21, revealed the resident had impaired cognition, required extensive assistance of two staff for bed mobility and extensive assistance of one staff for transfers and toileting.
Observation on 06/28/21 at 11:28 A.M. revealed Resident #09's call light was activated via the call button at the resident's bedside. The light was not observed to turn on outside of the room above the door.
Observation on 06/28/21 at 11:29 A.M. revealed Resident #18's (Resident #09's roommate) call light was activated via the call button at the resident's bedside. The light was not observed to turn on outside of the room above the door.
Interview on 06/28/21 at 11:35 A.M. with Registered Nurse (RN) #215 verified the light did not light up outside the room of Residents #09 and #18 and did not transmit a signal to the pagers carried by the staff.
2. Review of the medical record for Resident #16 revealed an admission date of 12/07/20. Diagnoses included chronic obstructive pulmonary disease, dementia with behavioral disturbance, anxiety disorder, major depressive disorder, and non-st elevation (NSTEMI) myocardial infarction. Review of the quarterly MDS assessment revealed the resident had intact cognition and required supervision for bed mobility, transfers, and ambulation.
Observation on 06/28/21 at 2:20 P.M. revealed Resident #16's call light was activated via the call button at the resident's bedside. The light was not observed to turn on outside of the room above the door.
Interview on 06/28/21 at 2:20 P.M. with State Tested Nursing Aide (STNA) #240 verified the light did not come on outside the door nor did not transmit a signal to the pagers carried by the staff. Further interview with STNA #240 revealed the call light cord was not plugged into the wall.

Based on medical record review, observation, and staff interview, the facility failed to maintain dignity while feeding Resident #44. The facility identified two residents who were dependent on staff for feeding. The facility census was 64.
Findings include:
Review of the medical record of Resident #44 revealed an admission date of 01/09/13. Diagnoses included dysphagia, protein-calorie malnutrition, major depressive disorder, cognitive communication deficit, chronic obstructive pulmonary disease (COPD), anxiety disorder, and cerebral infarction (stroke). Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/15/21, revealed the resident had impaired cognition and was dependent on the assistance of one staff for feeding.
Observation and interview on 06/28/21 at 11:43 A.M. revealed Resident #44 laying in bed. The right side of Resident #44's bed was against the wall and RN #139 was standing at the left side of the bed feeding Resident #44. RN #139 verified she was feeding Resident #44 while standing up and further stated she was right-handed so it was easier for her to feed the resident while standing up.
Interview on 07/01/21 at 10:00 A.M. with the Director of Nursing (DON) stated the expectation was for staff to be seated when feeding residents.

Based on record review and staff interview, the facility failed to accurately code a resident's fall status on the Minimum Data Set (MDS) assessment. This affected one (Resident #13) of 18 residents reviewed for accurate MDS assessments. The facility census was 64 residents.
Findings include:
Review of the medical record for Resident #13 revealed an admission date of 06/15/19. Diagnoses included dementia and transient cerebral ischemic attack.
Review of the progress notes revealed the resident had falls on 03/04/21, 11/22/20, and 11/07/20.
Review of the Minimum Data Set (MDS) assessments revealed a quarterly assessment was completed on 04/05/21, an annual assessment was completed on 02/11/21, and a quarterly assessment on 11/18/20. No additional MDS assessments were completed between 11/18/20 and 04/05/21.
Subsequent review of the MDS assessments, dated 04/05/21 and 02/11/21, revealed section J1800 was negative for any falls since the prior assessment.
Interview on 06/30/21 at 2:38 P.M. with Licensed Practical Nurse (LPN) #114 verified the MDS assessments for Resident #13, dated 04/05/21 and 02/11/21, were coded incorrectly and should have indicated there was a fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interviews, the facility failed to obtain a physician order for the use of oxygen, failed to administer oxygen as physician ordered, and failed to properly label the oxygen tubing during continuous use. This affected three residents (Resident #27, #44, and #215) of 23 residents receiving oxygen therapy. The facility census was 64.
Findings include:
1. Record review for Resident #27 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure and congestive heart failure. Review of the Minimum Data Set assessment, dated 05/05/21, revealed the resident was rarely/never understood.
Review of the physician orders, dated 06/2021, revealed there were no orders for the use of oxygen. After surveyor intervention on 06/29/21, there was a physician order for the use of oxygen at two liters via nasal cannula.
Observation of Resident #27 on 06/28/21 at 2:38 P.M. revealed the resident had oxygen tubing that was not labeled or dated during the time of use. Subsequent observation of Resident #27 on 06/29/21 at 2:35 P.M. revealed the oxygen tubing was still not labeled or dated. During this observation, Registered Nurse (RN) #212 verified the oxygen was running at three liters per minute and tubing was unlabeled or dated. The RN explained a contracted provider supplies the oxygen and they change out the tubing weekly, and they do not label or date the tubing.
2. Record review for Resident #215 on 06/29/21 at 1:58 P.M. revealed the resident was admitted to the facility on [DATE]. Diagnoses included asthma and emphysema. Review of the MDS assessment, dated 06/19/21, revealed the resident had intact cognition.
Review of the physician orders, dated 06/2021, revealed there were no orders for the use of oxygen. After surveyor intervention on 06/29/21, there was a physician order for the use of oxygen at two liters via nasal cannula.
Observation of Resident #215 on 06/28/21 at 3:22 P.M. revealed the resident had oxygen tubing that was not labeled or dated during the time of use. Subsequent observation of Resident #27 on 06/29/21 at 2:35 P.M. revealed the oxygen tubing still not labeled or dated. During the observation, RN #212 verified the oxygen was running at three liters per minute and the tubing was unlabeled or dated.
On 06/30/21 at 2:40 P.M., an interview with the Director of Nursing (DON) on 06/30/21 at 2:40 P.M. verified Resident #27 and #215 did not have an active order for oxygen in place until it was obtained on 06/29/21. The DON verified the physician orders were for two liters, not three liters for Resident #27 and #215.
3. Review of the medical record for Resident #44 revealed an admission date of 01/09/13. Diagnoses included chronic obstructive pulmonary disease (COPD) and cerebral infarction. Review of the quarterly MDS assessment, dated 06/15/21, revealed the resident had impaired cognition.
Review of the physician's orders revealed order on 08/20/20 for oxygen at two liters per minute as needed per nasal cannula six to eight per day and an order on 09/26/17 for one dose duoneb solution 0.5-2.5 (3.0) milligrams/3.0 milliliter solution every four hours as needed.
Review of the treatment administration record (TAR) revealed RN #139 signed off the oxygen as administered on 06/28/21 and 06/29/21.
Observations on 06/28/21 at 9:42 A.M. and 11:43 A.M, and on 06/29/21 at 3:00 P.M., and 4:08 P.M. revealed no oxygen concentrator nor oxygen tank in Resident #44's room.
Observation on 06/29/21 at 3:00 P.M. revealed a nebulizer placed on Resident #44's bedside table. The tubing did not contain any date to indicate when it was last replaced.
Interview on 06/29/21 at 4:08 P.M. with RN #139 verified there was no there was no date on the nebulizer tubing nor were there oxygen concentrator or tanks in Resident #44's room. The RN further stated Resident #44 had not received oxygen anytime recently. RN #139 verified the MAR had been signed off indicating the oxygen was administered when the oxygen had not been administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to report and submit a self-reported incident (SRI) of resident to resident physical abuse to the state agency within 24 hours. This affected one resident (#12) of one resident reviewed for abuse. The facility census was 73.
Findings include:
1. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with the following diagnoses; unspecified dementia with behavioral disturbance, anxiety disorder, unspecified psychosis not due to a substance or known physiological condition, and major depressive disorder. Review of Resident #12's annual Minimum Data Sets (MDSs) assessment dated [DATE] revealed the resident had severe cognitive impairment.
Review of Resident #12's progress note written by Registered Nurse (RN) #124 dated 12/19/18 revealed Resident #12 said a man came in and grabbed her wrist and knocked her stuff off of her door. Resident #12 was noted with a small skin tear and a bruise. Both residents were separated. Resident #12 was ordered a treatment for her wrist.
2. Medical record review revealed Resident #220 was admitted to the facility on [DATE] with the following diagnoses; transient cerebral ischemia attack (stroke), unspecified psychosis not due to substance or known physiological condition, Alzheimer's disease, and major depressive disorder. Resident #220 passed away at the facility on 01/20/19. Review of the resident MDS assessment dated [DATE] revealed the resident had severe cognitive impairment.
Review of Resident #220's progress note written by RN #124 dated 12/19/18 revealed a State Tested Nurse Aide (STNA) reported Resident #12 said Resident #220 came in her room, knocked decorations off her door and grabbed her wrist causing a skin tear with a small bruise. Both residents were separated and placed on 15 minute checks.
Review of the Activities Director (AD) #14's statement dated 12/19/18 revealed the AD was walking down the hallway and witnessed Resident #220 at Resident #12's doorway pulling at her decorations. Resident #12 approached Resident #220 at the same time and Resident #220 reached out and grabbed Resident #12's wrist. AD #14 intervened and redirected Resident #220 away from the doorway.
Interview with the Director of Nursing (DON) on 03/13/19 at 12:57 P.M., verified Resident #220 grabbed Resident #12 causing a bruise and an skin tear on 12/19/18. The DON revealed she investigated the incident and found Resident #220 was knocking down Resident #12's decorations and grabbed Resident #12's arm and his finger nail caught her arm leaving a skin tear. The DON confirmed a SRI was not completed regarding the resident to resident physical abuse between Resident #12 and Resident #220.
Review of the facility's Abuse and Neglect policy dated November 2018 revealed all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of property, are reported immediately, but not later than two hours after the allegation is made if the events that cause the allegation involve abuse or result in seriously bodily injury, or not later than 24 hours if the event that cause the allegation do not involve abuse or do not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to implement their abuse policy when they failed to submit a self-reported incident (SRI) to the state agency regarding a resident to resident physical abuse, and further failed to ensure a resident was free from resident to resident physical abuse. This affected one resident (#12) of one resident reviewed for abuse. The facility census was 73.
Findings include:
1. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with the following diagnoses; unspecified dementia with behavioral disturbance, anxiety disorder, unspecified psychosis not due to a substance or known physiological condition, and major depressive disorder. Review of Resident #12's annual Minimum Data Sets (MDSs) assessment dated [DATE] revealed the resident had severe cognitive impairment.
Review of Resident #12's progress note written by Registered Nurse (RN) #124 dated 12/19/18 revealed Resident #12 said a man came in and grabbed her wrist and knocked her stuff off of her door. Resident #12 was noted with a small skin tear and a bruise. Both residents were separated. Resident #12 was ordered a treatment for her wrist.
2. Medical record review revealed Resident #220 was admitted to the facility on [DATE] with the following diagnoses; transient cerebral ischemia attack (stroke), unspecified psychosis not due to substance or known physiological condition, Alzheimer's disease, and major depressive disorder. Resident #220 passed away at the facility on 01/20/19. Review of the resident MDS assessment dated [DATE] revealed the resident had severe cognitive impairment.
Review of Resident #220's progress note written by RN #124 dated 12/19/18 revealed a State Tested Nurse Aide (STNA) reported Resident #12 said Resident #220 came in her room, knocked decorations off her door and grabbed her wrist causing a skin tear with a small bruise. Both residents were separated and placed on 15 minute checks.
Review of the Activities Director (AD) #14's statement dated 12/19/18 revealed the AD was walking down the hallway and witnessed Resident #220 at Resident #12's doorway pulling at her decorations. Resident #12 approached Resident #220 at the same time and Resident #220 reached out and grabbed Resident #12's wrist. AD #14 intervened and redirected Resident #220 away from the doorway.
Interview with the Director of Nursing (DON) on 03/13/19 at 12:57 P.M., verified Resident #220 grabbed Resident #12 causing a bruise and an skin tear on 12/19/18. The DON revealed she investigated the incident and found Resident #220 was knocking down Resident #12's decorations and grabbed Resident #12's arm and his finger nail caught her arm leaving a skin tear. The DON confirmed a SRI was not completed and submitted regarding the resident to resident physical abuse between Resident #12 and Resident #220.
Review of the facility's Abuse and Neglect policy dated November 2018 revealed abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment that results in physical harm, or pain or mental anguish. All alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of property, are reported immediately, but not later than two hours after the allegation is made if the events that cause the allegation involve abuse or result in seriously bodily injury, or not later than 24 hours if the event that cause the allegation do not involve abuse or do not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interview, and review of facility policy, the facility failed to ensure a resident was free from a physical restraint. This affected one resident (#64) of one resident reviewed for physical restraints. The facility census was 73.
Findings include:
Medical record review revealed Resident #64 was admitted to the facility on [DATE] with the following diagnoses; cerebral infarction (stroke), major depressive disorder, cognitive communication deficit, chronic obstructive pulmonary disease (COPD), and anxiety disorder. Review of Resident #64's quarterly Minimum Data Set (MDSs) assessment dated [DATE] revealed the resident had severe cognitive impairment. The MDS further revealed the resident was totally dependent on staff with transfers and had a chair alarm.
Review of Resident #64's care plan revealed the resident had a self releasing alarm seat belt in place on her wheelchair. The care plan identified Resident #64's seat belt as an enabler due to it enabling her to maintain an appropriate position in her wheelchair. The care plan further revealed Resident #64 was able to release her seat belt on her own.
Review of Resident #64's physical restraint assessment dated [DATE] revealed the resident leaned to the right, had poor trunk control, was unable to recover the loss of balance when sitting and was unable to stand except with weight bearing support of two staff. Resident #64 demonstrated the ability to release and reapply the Velcro self releasing alarming seatbelt every time upon request, therefore the seat belt was not considered a restraint.
Review of Resident #64's progress note dated 03/04/19 revealed an interdisciplinary team meeting was held on 02/28/19. Resident #64's self releasing alarm seat belt was in use to increase resident's sense of safety. Resident #64 was reported to be recently observed fastening and unfastening her seatbelt at random times. The note also revealed the seat belt did not restrain the resident from exiting the chair.
Observation of Resident #64 on 03/14/19 at 9:03 A.M., revealed resident to be sitting in her wheelchair in the dining room with her Velcro self releasing alarming seat belt in place.
Observation of Resident #64 on 03/14/19 at 9:11 A.M., revealed Registered Nurse (RN) #124 asked Resident #64 to take off her Velcro self releasing alarming seat belt. RN #124 asked the resident several times and cued her by pointing to the seat belt connector. Resident #64 stared at RN #124 and after being cued multiple times she was able to slightly lift up the plastic clip to her seat belt setting off the alarm. Resident #64's seat belt was remained fastened with the Velcro. RN #124 verified Resident #64 was able to lift the plastic clip on her seat belt after being cued multiple times, however the seat belt remained fastened with the Velcro. RN #124 revealed the resident became agitated at times when attempting to remove the seat belt.
Review of the facility's Physical Restraints policy dated 01/08/12 revealed physical restraints to be any manual method or physical or mechanical device, material or equipment attached to or adjacent to the resident's body that the individual cannot easily remove which restricts freedom of movement or normal access to one's own body.