Facility I.d. Number: 0012765
Date of Survey: 3/11/03
INCIDENT REPORT INVESTIGATION OF 02/23/03
The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident, in accordance with each resident's comprehensive assessment and plan of care. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.
Objective observations of changes in a resident's condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be made by nursing staff and recorded in the resident's medical record.
All necessary precautions shall be taken to assure that the residents' environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.
These requirements are not met as evidenced by:
Based on observation, record review and interview the facility failed to:
a) ensure that residents' side rails were free of accident hazards;
b) change a resident's (R1) bed alarm sensor as scheduled on R1's treatment sheet and ensure the bed
alarm sensor was properly secured;
c) include the safety of the side rails in its Quality assurance after the 2 incidents involving side rails;
d) take corrective actions involving other side rail incidents (R2, R3); and
e) assess residents for the need/use of siderails (R1, R2, R3).
This is for 3(R1, R2, R3) of 3 residents in the sample, 7 of 14 beds on Wing 4 and 20 of 28 beds on the Alzheimer's Unit.
This caused R1's death by asphyxiation on 2/23/03, shoulder, wrist and chest injuries to R3 on 10/21/02 and R2 getting her head caught in the side rail on 12/30/02.
The findings include:
1. R1 has diagnoses to include Alzheimer's with Agitation, Depression and Cerebral Vascular Accident per review of the Physician Order Sheet (POS) for February, 2003. Review of R1's Minimum Data Set (MDS) dated 2/6/03 shows R1 as being moderately impaired in cognitive skills; needing extensive assistance in bed mobility and transfer which requires the assist of one. R1 resided on the facility's Alzheimer Unit.
Review of the facility's Incident Report of 2/23/03 notes the following:
'1:00 a.m. February 23, 2003: E5 (CNA) enters R1's room to do her bed check. At that time, staff members hears E5 start to scream. E6 (CNA) respond to the screams... At that time, both CNAs noted R1 to be in the following position. R1's head was facing the bathroom, which is located to the right when facing south. Her head was positioned between a quarter side rail and the mattress. R1's feet and trunk were facing the north portion of her room. The body appeared to be "slanted" per both CNAs. R1 was wearing her non-ambulatory heel protectors, and the CNAs noted an indentation from the right protector in R1's left knee. She also had a skin tear to the right arm. When E6 entered the room, she immediately was able to pull R1's head from between the side rail and mattress frame. She then rolled R1 onto her back. At that time E4 (RN-charge nurse) entered the room... she noted that R1 was dead at that time. She noted a slight bruise to the right side of R1's neck. 3:30 a.m. Z1(Deputy Coroner)arrived and instructed R1's family member that an autopsy would need to be completed in order to state the cause of death.
February 24, 2003: At approximately 12:30 p.m. Z1 came to the facility to deliver the preliminary results from the autopsy performed on R1. The cause of death was noted to be asphyxiation which would have been a result from the incident on Sunday, February 23, 2003.'
During tour on 2/27/03 with E3, R1's bed and side rails were observed. The following was noted. The side rails were approximately 2 inches above the level of the mattress. There was an air mattress on top of R1's regular mattress. The bars in the middle (holding up the rails) left a gap approximately 4-5 inches from the middle to outer edge of the side rails. There was also a gap between the rails and the mattress of approximately 3 inches. All the beds on this unit (Alzheimer) were observed and 20 of 28 beds had the same gaps as R1's bed. The beds on Wing 4 were also observed and 7 of 14 beds also had the same gaps and the same type of beds and side rails.
The bed alarm sensor strip on R1's bed was noted to have a date of 12/17/02 on it. Review of R1's treatment sheet for December, 2002, documents R1's sensor strip should have been changed on 12/31/02. This was 54 days overdue. E8(charge nurse) was asked on 2/27/03 how did staff know when to change the bed alarm sensor strips. E8 stated, "It is changed (scheduled) by the treatment sheet." E2(Director of Nursing) was asked if she was aware that R1's strip had a date of 12/17/02 on it and E2 stated, "Yes." E2 was interviewed on 2/27/03 in her office at 10:15 a.m. E2 stated, "A representative of the company that sells the alarm units said the sensor strips could be used up to 45 days even though the strip says 30 days on the strip . R1 had alarm unit (which is a wheelchair or bed strip under the resident). It's set off by pressure and any movement. There is a box alarm in the resident's room, one rover (box that can be moved). When it sounds a number shows up and staff know they need to go down and assist resident. " E2 was asked why didn't R1's alarm go off. E2 stated, "When the two CNAs went back in room, R1's left cheek was against sensor strip so it may not have alarmed."
E5 was interviewed on 2/28/03 at 9:55 a.m.. E5 was asked if R1's bed alarm sensor was alarming when she entered R1's room on the night of 2/23/02. E5 stated, " R1's head was on the strip and the strip was on the side and that is why it did not sound." When asked if strips are taped down E5 stated, "R1's strip was taped but it came off. Masking tape had been used but it came off."
E4(charge nurse) was interviewed on 2/27/03 at 11:40 a.m. E4 was asked if she saw the position of the bed alarm sensor strip on R1's bed on the night of the incident of 2/23/03. E4 stated, "I didn't get to see the position of the strip."
2. R3 has diagnoses to include Alzheimer's Dementia and Anxiety per review of February, 2003 POS. Review of R3's MDS dated 12/12/02 shows R3 has severe cognitive impairment and requires total dependence for bed mobility and requires a 2 person assist.
Review of an incident dated 10/21/02 12:30 a.m. shows the following. CNA found resident with her head caught in the side rail. R3 was propped on right side with pillows. R3 sustained a very reddened right shoulder, left chest and left wrist. The section under Corrective Action shows: 'Walking rounds between shifts.'
E1(Administrator) was interviewed on 2/28/03 and was asked about the incidents with R2. E1 stated, "R3 had the same kind of bed that R1 had. Wing 4 had the same beds purchased for them." The same beds were observed on Wing 4 during tour on 2/27/03.
3. R2 has diagnoses to include Alzheimer and Dementia per review of POS of February, 2003. R2's MDS dated 11/22/02 shows R2 is moderately impaired in cognitive skills; requires limited assistance in bed mobility and requires a one person assist. R2 resided on the Alzheimer's Unit.
Review of an incident dated 12/30/02 3:30 a.m. notes the following: R2 found dangling from side of bed near bathroom with face pressed against railing and body partially on floor. The Incident Report shows R2 has severe cognitive impairment and that the probable cause of event: turning in bed with body gravitated to foot board. The section labeled Corrective Action taken is blank.
Observation of R2's bed on 2/27/03 showed a bed identical to R1's.
4. All of these incidents (3) occurred while the residents were in identical beds with the same side rails. There was a pattern of times that these incidents occurred. They occurred between 12:30 a. m. to 3:30 a.m.
All the beds (28) on the Alzheimer Unit were observed on 2/27/03 with E3(Assistant Director of Nursing) and E8(charge nurse). Twenty three of 28 beds had side rails that had gaps of approximately 3 inches out from the mattress and a gap of approximately 4-5 inches from where the bars were attached to the bed frame to the end of the side rail.
5. On 2/28/03 at 9:15 a.m E1 was asked if side rails had been reviewed by their Quality Assurance. E1 reviewed the facility's Quality Assurance minutes for November, 2002 and January, 2003 and stated, "No, there is nothing in the notes and I don't recall discussing side rails."
Review of R1's Rehab Assessment dated 2/2/02 the Devices and Restraints section is blank and a line is crossed through it.
6. Review of R1's Resident Assessment Protocol (RAP) dated 2/2/02 for physical restraint does not address the use of side rail. The section for Devices and Restraints is crossed out.
R3's care plan of 12/12/02 under Mobility shows R3 doesn't make any attempt to get out of bed or chair anymore. R3's MDS dated shows R3 is totally dependent on staff in the area of mobility. On 2/28/03 at 11 a.m. E2 stated, "R1 , R2 and R3 used the side rails for mobility."
R2's care plan of 2/20/02 shows 'per family request affixed a lower siderail to the toilet side of the bed.' There is no assessment for the need/use of this siderail.
7. On 2/27/03 at 10:15 a.m E2 was asked what was the facility's procedure for assessing the need for side rails. E2 responded, "The nurses use their judgment."