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- Complaint #AR00028818 was substantiated, all or in part, with deficiencies cited.
- Regs out of compliance –
- N 128 – Failed to ensure a physical restraint did not result in injury for 1 client who received a head injury during a physical restraint.
- N 142 – Failed to ensure an order for a physical and chemical restraint was not received at the same time and failed to ensure a physical restraint was utilized long enough to determine its effectiveness before the administration of a chemical restraint for 1 client.
- N 147 – Failed to ensure the documented times on the Physician’s Order and the time on the ESI Report were the same for 1 client who was placed in a physical restraint.
- N 188 – Failed to ensure all staff involved in an ESI were present at the client debriefing for 1 client.
- N 189 – Failed to ensure all staff involved in an ESI were present at the staff debriefing for 1 client.
- N 207 – Failed to report a serious occurrence to the appropriate agencies for 1 client who received a head injury during a physical restraint.
- Plan of Correction: DON provided counseling and additional education to LPN involved in incident, DON identified 50 ESIs in the past 30 days by record review with any negative findings corrected, DON provided written education to all nursing staff, DON will check ESI documentation the next business day for 8 weeks or until compliance is verified by OLTC.
- A revisit was conducted on 12/14/22 and facility was still not in substantial compliance with the following participation requirements:
- N100 – Failed to meet the Condition of Participation for the Use of Restraint and Seclusion at N100 as evidenced by the facility’s failure to meet the Standard for Protection of Residents at N130 and the Standard of Orders for the Use of Restraint or Seclusion at N140 and N142.N130 – Failed to ensure a client was released from a physical restraint as soon as the emergency situation had resolved for 1 client. Failed to ensure a chemical restraint was not administered after the emergency situation had ended for 1 client.N140 – Failed to ensure an order for seclusion was received for 1 client.N142 – Failed to ensure an order for a physical and chemical restraint was not received at the same time for 1 client and a physical restraint was utilized long enough to determine its effectiveness before the administration of a chemical restraint for 1 client.
- N188 – Failed to ensure all staff who participated in a physical restraint were present at the client debriefing for 1 client.
- Plan of correction: DON identified 48 ESI packets for 11 clients in the past 30 days by record review to ensure clients were not affected. DON provided reeducation, counseling, and additional education to staff. DON will monitor ESI documentation for 8 weeks or until OLTC has verified compliance.
