Eldercare of Alton Facility I.D. Number: 0023317 Date of Survey: 06/26/03 Complaint Investigation "A" VIOLATION(S): Physical restraints shall not be used on a resident for the purpose of discipline or convenience. Nonemergency use of Physical Restraints A physical RESTRAINT MAY BE USED ONLY WITH THE INFORMED CONSENT OF THE RESIDENT, THE RESIDENT’S GUARDIAN, OR OTHER AUTHORIZED REPRESENTATIVE. (Section 2-106(c) of the Act) Informed consent includes information about potential negative outcomes of physical restraint use, including incontinence, decreased range of motion, decreased ability to ambulate, symptoms of withdrawal or depression, or reduced social contact. The facility shall provide a Resident Services Director who is assigned responsibility for the coordination and monitoring of the resident’s overall plan of care. The director of nurses or an individual on the professional staff of the facility may fill this assignment to assure that residents’ plans of care are individualized, written in terms of short and long-range goals, understandable and utilized; their needs are met through appropriate staff interventions and community resources; and residents are involved, whenever possible, in the preparation of their plan of care. (B). Based on interviews, observation, resident record review, policy review and review of "Record of Employee Performance Observation Review" it is determined that the facility failed to keep one resident (R2) free from physical restraints when R2 was discovered tied to the toilet at about 11:20 p.m. on 05/13/03. Findings include: Review of R2's record documents diagnoses of Alzheimer and dementia. R2's annual assessment 04 /17/03 documents that R2 has short and long term memory loss and is severely impaired cognitively for daily decision making. R2's care plan includes that resident attempts to exit doorways due to cognitive loss and dementia, has a motion alarm at R2's doorway at bedtime, a body alarm at bedtime, and is to be observed all shifts for unsteady gait. R2 was found tied to the toilet with her hospital nightgown on 05/13/03 at about 11:20 p.m. Review of facility policy with E1 (administrator) verifies that residents are not to be tied/restrained to the toilet. Interview with E1, and E2 on 06/03/03 and E3 on 06/05/03 confirms that E3 did tie R2 to the toilet with R2's nightgown on 05/13/03 at about 10:30 p.m. R2 was not found until the midnight shift staff member , E4 (Certified Nurses Aide) found R2 tied to the toilet during rounds at about 11:20 p.m. Interview with E2 on 06/03/03 indicates that she received a phone call from E7 (Registered Nurse) at home on 05/13/03 at about 11:20 p.m. informing her of the incident with R2. During interview of E3 on 06/05/03, E3 indicated that R2 was up and following E3 down the hall on 05/13/03. Call lights were going off and E3 believes that call lights should be answered whether it's her assigned resident or not. In order to answer these call lights, E3 indicates that she did tie R2 to the toilet armrests with R2's nightgown. E3 states that she has never done this since this practice became unacceptable years ago, nor will she do this ever again in the future. Interview with E4 on 06/19/03 indicates that on 05/13/03 she came on duty and E7, Registered Nurse (R.N.) asked her where R2 was, as she wasn't in her bed or room, so E4 checked further and found R2 tied to the toilet with her hospital nightgown. E4 immediately retrieved E7 to view R2. R2 was untied and assessed. E2 was called for further instructions. Interview with Z1 on 06/25/03 at about 9:45 a.m. indicates that she knew nothing about the incident with R2 being tied to the toilet. R2 can get up and wander through facility without falling, however staff or family should attend R2 when R2 is toileted. R2 should have never been tied to the toilet and left unattended. Observation and attempt to interview R2 on 06/03 and 06/05/03 indicates that R2 is confused. E2 was informed by E5 on 05/22/03 at about 3:00 p.m. as to the identity of the staff member involved in tying R2 to the toilet. E5 confirmed when interviewed on 06/20/03 that after she was made aware of the identity of the involved staff member by E8 (C.N.A.) and E9 (C.N.A.), she immediately informed E2. E2 came to the facility on 05/23/03 at 4:30 a.m. , at the beginning of E3's shift and re-interviewed E3, (Certified Nurses Aide) which resulted in a written warning for E3. E3 received a verbal and written warning in regard to the above. |