PRINTED: 09/06/2017 DEPARTMENT OF HEALTH AND · PDF filea. building _____ (x1) provider/supplier/clia identification number: statement of deficiencies and plan of correction (x3) date

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(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

(X3) DATE SURVEY

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PRINTED: 09/06/2017FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

225040 08/24/2017

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STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

770 CONVERSE STREETJEWISH NURSING HOME OF WESTERN MASS

LONGMEADOW, MA 01106

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

F 000 INITIAL COMMENTS F 000

ACTS Reference Number(s): MA00026493,

MA00026543, MA00026599, and MA00026616

During a complaint investigation, conducted

08/22/17 and 08/23/17, it was determined the

Facility was in Immediate Jeopardy for F 157, F

281, F323, and F 461. The Facility failed to notify

the attending Physician (the Medical Director) of

two cases of side rail entrapment at the time of

occurrence. The Facility failed to accurately

report to the attending Physician the condition of

a resident's body at the time of death.

The Facility continued to fail to ensure that the

Medical Director was informed of one of the side

rail entrapment incidents at the time of survey.

The Facility failed to assess residents for the risk

of entrapment prior to the installation of side rails.

The Facility failed to have a policy and procedure

in place for the implementation, assessment, and

reassessment for the use of side rails.

The Facility failed to obtain consent for the use of

side rails from the resident or the resident's

representative, including a review of the risks and

benefits, prior to the installation of the side rails.

At the time of the Survey, the Facility failed to

produce documentation to ensure correct

installation, use, and maintenance bed rails.

At the time of the of the Survey the Facility failed

to provide information to ensure the installation

and maintenance of side rails was conducted in

accordance with manufacturer's

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Electronically Signed

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that

other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete 65Q411Event ID: Facility ID: 0772 If continuation sheet Page 1 of 32

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F 000 Continued From page 1 F 000

recommendations and specifications, and that

they conducted regular inspections of side rails in

an attempt to identify areas of possible

entrapment.

At the time of the Survey, the Facility failed to

produce documentation to ensure that side rails,

mattresses, and bed frames were compatible.

F 157

SS=J

483.10(g)(14) NOTIFY OF CHANGES

(INJURY/DECLINE/ROOM, ETC)

(g)(14) Notification of Changes.

(i) A facility must immediately inform the resident;

consult with the resident’s physician; and notify,

consistent with his or her authority, the resident

representative(s) when there is-

(A) An accident involving the resident which

results in injury and has the potential for requiring

physician intervention;

(B) A significant change in the resident’s physical,

mental, or psychosocial status (that is, a

deterioration in health, mental, or psychosocial

status in either life-threatening conditions or

clinical complications);

(C) A need to alter treatment significantly (that is,

a need to discontinue an existing form of

treatment due to adverse consequences, or to

commence a new form of treatment); or

(D) A decision to transfer or discharge the

resident from the facility as specified in

§483.15(c)(1)(ii).

(ii) When making notification under paragraph (g)

F 157 9/6/17


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(14)(i) of this section, the facility must ensure that

all pertinent information specified in §483.15(c)(2)

is available and provided upon request to the

physician.

(iii) The facility must also promptly notify the

resident and the resident representative, if any,

when there is-

(A) A change in room or roommate assignment

as specified in §483.10(e)(6); or

(B) A change in resident rights under Federal or

State law or regulations as specified in paragraph

(e)(10) of this section.

(iv) The facility must record and periodically

update the address (mailing and email) and

phone number of the resident representative(s).

This REQUIREMENT is not met as evidenced

by:

Based on records reviewed and interviews, for 2

of 5 sampled residents (Resident #4 and

Resident #5), the Facility failed to notify the

attending Physician of the circumstances

surrounding two incidents of side rail entrapment.

- On 07/31/17, an Incident Report indicated

Resident #5 was found, by a Certified Nurse Aide

(CNA) #4, entrapped between the bed and the

side rail. CNA #4 said she observed Resident

#5's head was on the mattress, with the bottom

bar of the side rail across the front of his/her

neck, and his/her body and his/her legs off the

bed. CNA #2 said he observed Resident #5's

body to be outside the bed with his/her head on

the bed with the bottom of the side rail across

his/her neck and Resident #5 was "just hanging

there", looked "terrified", and he/she was holding

Preparation and/or execution of this plan

of corrections does not constitute

admission or agreement by the provider of

the truth of the facts alleged or

conclusions set forth in the statement of

deficiencies. The plan of correction is

prepared and/or executed solely because

it is required by the provisions of federal

and state law. This Plan of Correction is

the facility's credible allegation of

compliance.

• In regards to R#4 and R#5, the attending

physician has been notified of the

circumstances surrounding the alleged

side rail entrapment.

• The attending physician, or if

unavailable, the Medical Director, will be


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onto the side rail with both hands as if "holding on

for dear life", or words to that effect.

- On 08/15/17, CNA #2 said he observed that

Resident #4's head was twisted sideways and

held firmly in place from just behind the eyes by

the bed frame and bottom bar of the side rail.

CNA #2 said that the side rail had to be physically

manipulated up and away from Resident #4's

head in order to reposition his/her body back onto

the bed. Resident #4's face was observed to be

swollen and his/her lips were cyanotic (a bluish

discoloration of the skin due to low levels of

oxygen in the blood), and an indentation from the

bottom bar of the side rail was observed running

partway down Resident #4's face. Resident #4

was determined to be deceased.

Findings include:

1. Resident #5 was admitted to the Facility in

February 2017 with diagnoses which included:

muscle weakness, dementia, and hypertension

(HTN).

A Significant Change Minimum Data Set (MDS),

dated 06/07/17, indicated that Resident #5

required the extensive assistance of 2 or more

persons for bed mobility and had moderate

cognitive impairment.

The Incident Investigation Report, dated

07/31/17, indicated that Resident #5 was found

by a CNA, "entrapped" between the bed and the

side rail.

Surveyor #1 and Surveyor #2 interviewed

Certified Nurse Aide (CNA) #4 at 11:19 A.M. on

8/23/17. CNA #4 said that on 07/31/17 at

notified of any unusual circumstances

surrounding an identified incident that may

constitute the potential for serious harm or

death.

• The facility has reviewed its incident

policy and has developed a reportable

death/RN pronouncement of death policy

along with a reportable death review tool

which identifies the requirements for

notifying the attending physician and/or

the Medical Director of an

unexpected/unusual death.

• Staff has been in-serviced and has

demonstrated an understanding of the

requirements regarding the notification of

a physician and/or the Medical Director in

the event of an unexpected or unusual

death.

• The facility Administrator and Director of

Nursing have been provided an in-service

regarding the Commonwealth of

Massachusetts reporting requirements.

• An audit tool has been implemented for

the reporting of incidents, including those

that may constitute the potential for

serious harm or death are reviewed to

ensure they are reported. The results of

these audits will be reported to the facility

Quality Assurance and Performance

Improvement Committee on a monthly

basis for one year and then quarterly

thereafter until substantial compliance has

been determined.

• The Director of Nursing is responsible

for the completion and the ongoing

compliance with this individual plan of

correction.


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approximately 1:00 P.M., she assisted Resident

#5 into bed and approximately 45 minutes later,

she walked by Resident #5's room glanced into

Resident #5's room, but she could not see

Resident #5's legs in the bed, and so entered the

room to check on him/her. CNA #4 said she

observed Resident #5 with his/her head on the

mattress, the bottom of the side rail across the

front of his/her neck, and his/her legs off the bed.

CNA #4 said she and CNA #3 could not move

Resident #5 without choking him/her. CNA #4

said CNA#2 assisted them to move Resident #5

from under the side rail and back into bed. CNA

#4 said she informed the Unit Manager.

Surveyor #1 and Surveyor #2 interviewed CNA #3

at 9:34 A.M. on 8/23/17. CNA #3 said she heard

CNA #4 call for help, and when she responded,

she observed Resident #5 "hanging" from the

side rail and "holding on for dear life", or words to

that effect. CNA #3 said she and CNA #4 called

for more help because there was no way they

could have moved Resident #5 by themselves.

CNA #3 said she, CNA #2, and CNA #4 moved

Resident #5 from under the side rail and back

into bed.


at 9:00 A.M. on 8/23/17. CNA #2 said he heard a

CNA screaming for help and when he went into

Resident #5's room, he observed Resident #5's

head on his/her mattress with the bottom of the

side rail across the front of his/her neck, and

his/her body hanging off the bed on the opposite

side of the rail. CNA #2 said Resident #5 was

holding on to the side rail with both hands as if

he/she was "hanging on for dear life", or words to

that effect. CNA #2 said Resident #5 was clearly

in distress and appeared "petrified." CNA #2 said


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CNA #3 and CNA #4 were in Resident #5's room

trying to figure out how to get Resident #5's head

out from between the mattress and the side rail

without hurting him/her. CNA #2 said one CNA

held the side rail to keep it still, another held

Resident #5's head still, and he picked up

Resident #5's body and tried to hold him/her as

flat as possible so they could slide his/her head

out and place him/her onto the bed.

The Interdisciplinary Note, dated 07/31/17,

indicated that Resident #5 was found stuck

between his/her air mattress and the left side rail,

and that a voicemail was left for the Medical

Director.

Surveyor #1 and Surveyor #2 interviewed the

Medical Director at 1:46 P.M. on 8/22/17 and at

11:11 A.M. on 8/24/17. The Medical Director said

she did not know of the alleged incident with

Resident #5 until it was briefly mentioned after

Resident #4's death on 8/15/17. The Medical

Director said she was not given any information

about Resident #5 being entrapped in the side rail

and she was on a leave of absence and did not

return until several days after it occurred. During

the interview with the Surveyors, the Medical

Director reviewed Resident #5's clinical record

and observed a progress note, dated 07/31/17,

which indicated that a voicemail was left for her

regarding the alleged incident. The Medical

Director said she did not recall receiving any

voicemail or other notification about the alleged

incident. The Medical Director said that as of

8/24/17, Facility staff had not spoken with her

about the incident with Resident #5 and she had

not seen the related Incident Report.

2. Resident #4 was admitted to the Facility in in


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December 2014, and readmitted in July 2017,

with diagnoses which included: HTN, dementia,

and depression.

The Quarterly MDS, dated 07/30/17, indicated

that Resident #4 required the extensive physical

assistance for 2 or more persons with bed

mobility and had severe cognitive impairment.

CNA #2 said that on 08/15/17 between 7:00 A.M.

and 7:30 A.M., he entered Resident #4's room

and observed Resident #4 lying in bed with

his/her legs hanging off of the bed from

approximately mid-thigh down. CNA #2 said

Resident #4's head was twisted sideways and to

the right, in-between the bottom of the side rail

and the frame of the bed, and he/she appeared

deceased based on the color and temperature of

his/her skin. CNA #2 said he had to physically pull

on the side rail in order for staff to "pry", or words

to that effect, Resident #4 out and reposition

him/her on the bed. CNA #2 said that when

Resident #4 was repositioned in the bed, a large

amount of saliva poured out of his/her mouth, and

he observed an indentation down the right side of

Resident #4's face from where the side rail bar

had been.

CNA #3 said that on 08/15/17, she responded to

CNA #2's requests for help with Resident #4.

CNA #3 said that when she entered Resident #4's

room, she observed him/her lying in bed with


approximately mid-thigh down, with his/her feet

touching the floor. CNA #3 said Resident #4's

head appeared to be "stuck" between the

mattress and the bottom of the side rail, and a

golf ball sized pool of saliva was on the floor

under Resident #4's mouth. CNA #3 said that in


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order to reposition Resident #4 onto the bed,

CNA #2 had to pull on the side rail so that staff

could free Resident #4's head. CNA #3 said

Resident #4 was obviously deceased when she

entered the room, that his/her legs were cold to

the touch and were bluish in color.

CNA #4 said that on 08/15/17, she entered

Resident #4's room in response to CNA #2's

requests for help. CNA #4 said Resident #4

appeared deceased, that he/she was a "smoky

grey and blue in color", or words to that effect,

and had saliva running out of his mouth onto the

floor. CNA #4 said Resident #4's head was

twisted to the right side, and his/her face was

between the bottom of the side rail and the

mattress. CNA #4 said the side rail had to be

physically pulled on to move it away from

Resident #4's face so that staff could reposition

him/her onto the bed. CNA #4 said she observed

a mark from the eye to the jawline, like an

indentation, consistent with where the bottom of

the side rail had been on his/her face.

Surveyor #1 and Surveyor #2 interviewed Nurse

#2 at 10:15 A.M. on 8/22/17. Nurse #2 said that

when she responded to CNA #3's cries for help

from Resident #4's room on 08/15/17, she

observed Resident #4 in bed, with his/her legs

hanging off of the bed and his/her face "stuck" in

the side rail. Nurse #2 said Resident #4's face

from just behind the eyes forward, was protruding

beyond the side rail, with the bar from the side rail

running along his/her face. Nurse #2 said

Resident #4's face appeared swollen, his/her lips

cyanotic, with saliva running out of his/her mouth,

and his/her legs were blue in color and mottled.

Nurse #2 said Resident #4 did not have a pulse

at that time. Nurse #2 said CNA #2 had to pull the


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side rail upwards and out away from the bed in

order to be able to reposition Resident #4 onto

the bed, but that it still took effort to free Resident

#4's head from between the bed frame and

bottom of the side rail. Nurse #2 said she called

the Medical Director, and informed her that

Resident #4 was found pulseless, with his/her

face in the side rail.

The Medical Director said she was told that

Resident #4 was found pulseless and had passed

away but it wasn't until 08/17/17 or 08/18/17 that

staff told her Resident #4's head had been

trapped in the side rail and that staff was

concerned that the use of side rails contributed to

Resident #4's death.

F 281

SS=G

483.21(b)(3)(i) SERVICES PROVIDED MEET

PROFESSIONAL STANDARDS

(b)(3) Comprehensive Care Plans

The services provided or arranged by the facility,

as outlined by the comprehensive care plan,

must-

(i) Meet professional standards of quality.


by:

F 281

Based on records reviewed and interviews, for

one of five sampled residents (Resident #4), the

facility failed to accurately report, to the Physician

and Medical Examiner, the position and the

condition of the body at the time of death.

- The Facility failed to ensure that the Medical

Director was provided with accurate information

related to Resident #4 having to be pried from

between his/her mattress and side rail.


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- The Facility failed to follow acceptable

standards related to notification of the Medical

Examiner and related to the Registered Nurse

Pronouncement of Death.





CNA #2 said that the side rail had to be physically



the bed.

Findings include:

Massachusetts General Law, Part One, Title V1,

Chapter 38, Section 3, indicated that it shall be

the duty of any person having knowledge of a

death which occurs by accident or unintentional

injury, regardless of time interval between the

incident and death, and regardless of whether

such injury appears to have been the immediate

cause of death, or a contributory factor thereto or

death under suspicious or unusual

circumstances.



with diagnoses which included dementia.




mobility and had severe cognitive impairment.

The Incident Investigation Packet, dated

08/12/17, indicated that at approximately 3:15


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P.M., Resident #4 fell forward out of his/her

wheelchair onto the floor. The packet indicated

that Resident #4 sustained and

abrasion/contusion to the right forehead, and a

skin tear to the webbing between the thumb and

forefinger on his/her right hand.


Certified Nurse Aide (CNA) #2 at 9:00 A.M. on

8/23/17. CNA #2 said that on 08/15/17 between

7:00 A.M. and 7:30 A.M., he observed Resident

#4 lying in bed on his/her left side, with his/her

legs hanging off of the bed from approximately

mid-thigh down. CNA #2 said Resident #4's head

was twisted sideways and to the right, in-between

the bottom of the side rail and the frame of the

bed, and his/her right hand was holding onto the

side rail. CNA #2 said he had to physically pull on

the side rail in order for staff to "pry", or words to

that effect, Resident #4 out and reposition

him/her on the bed because Resident #4's head

was under the side rail and prevented them from

being able to lower the side rail. CNA #2 said that

when Resident #4 was repositioned in the bed, he

observed an indentation down the right side of


had been. CNA #2 said he told the Director of

Nurses (DON), on 08/15/17 or 08/16/17, how

Resident #4 was when he found him/her on

08/15/17.


at 9:34 on 8/23/17. CNA #3 said that on 08/15/17,

she observed Resident #4 lying in bed with


approximately mid-thigh down and his/her feet


head was twisted to the right and appeared to be

"stuck" between the mattress and the bottom of


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the side rail. CNA #3 said that in order to

reposition Resident #4 onto the bed, CNA #2 had

to pull on the side rail so that staff could free

Resident #4's head because his/her head was

under the side rail and prevented them from

lowering the side rail. CNA #3 said that when she

told the DON how she observed Resident #4, the

DON told her "she didn't see what she saw", or

words to that effect. CNA #3 said she told the

DON that she was not going to say anything

differently than what she had seen, or words to

that effect.


at 11:19 on 8/23/17. CNA #4 said that on

08/15/17, she observed Resident #4 lying in bed

with the lower part of his/her body off of the bed.

CNA #4 said Resident #4's head was twisted to

the right side, with his/her face was between the

bottom of the side rail and the mattress. CNA #4

said the side rail had to be physically pulled on to

move it away from Resident #4's face so that staff

could reposition him/her onto the bed. CNA #4

said she observed a mark from the eye to the

jawline, like an indentation, consistent with where

the bottom of the side rail had been on his/her

face.



on 08/15/17, she observed Resident #4 in bed

with his/her legs hanging off of the bed and

his/her face "stuck" in the side rail. Nurse #2 said

Resident #4's face from just behind the eyes

forward was protruding beyond the side rail, with

the bar from the side rail running along his/her

face. Nurse #2 said Resident #4's face appeared

swollen, his/her lips cyanotic, with saliva running

out of his/her mouth, and his/her legs were blue


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in color and mottled (irregular patches of skin

discoloration as a result of diminished circulation).





the bed because the position of Resident #4's

head prevented staff from being able to lower the

side rail. Nurse #2 said it still took effort to free

Resident #4's head from between the bed frame

and bottom of the side rail. Nurse #2 said she

called the Medical Director, and informed her that


face in the side rail. Nurse #2 said she informed

the DON that staff found Resident #4 with his/her

face under the side rail.

There was no indication that the Medical

Examiner was notified at the time of the

Registered Nurse Pronouncement of Death that

Resident #4 was found under the side rail on

his/her bed and was deceased.




that on 08/15/17, she was told that Resident #4

was found pulseless and had already passed

away, and so gave an order for the registered

nurse to pronounce death. Although the DON

informed the Physician/Medical Director of

Resident #4's death, the Medical Director said it

was not until 8/17/17 or 8/18/17, that she was

informed by staff that there was a concern related

to side rails. The Medical Director said, had she

been aware of those concerns, especially given

his/her fall a few days prior, she would have told

the Facility to refer the case to the medical

examiner.


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The Commonwealth of Massachusetts

Department of Public Health Registry of Vital

Records and Statistics Pronouncement of Death,

dated 08/15/17 and completed by the DON,

indicated that Resident #4's time of death was

7:35 A.M., and the case was not referred to the

Medical Examiner.


DON at 3:12 P.M. on 8/22/17. The DON said she

felt that Resident #4 had "some sort of "cardiac

event", or words to that effect.

Although the DON said she felt that Resident #4's

death was related to a "cardiac event", or words

to that effect, the DON was not present at the

time that Resident #4 was found, did not assist in

removing Resident #4's head and body away

from the side rail, and her comment was not

consistent with the four staff members who

actually found, witnessed, and assisted in moving

Resident #4 from the side rail on 8/15/17.

2. The Physician's Interim/Telephone Order for

RN (Registered Nurse) pronouncement of

Resident #4 indicated that the order was received

at 7:35 A.M. on 08/15/17.

The Medical Director said that when she was

contacted on 08/15/17 about Resident #4 being

found pulseless, she was informed that the DON

was in the room conducting the RN

pronouncement. When asked if she had already

given the order for the RN pronouncement at that

time, the Medical Director said "well, the DON

was doing an assessment" of Resident #4, or

words to that effect.


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F 323

SS=L

483.25(d)(1)(2)(n)(1)-(3) FREE OF ACCIDENT

HAZARDS/SUPERVISION/DEVICES

(d) Accidents.

The facility must ensure that -

(1) The resident environment remains as free

from accident hazards as is possible; and

(2) Each resident receives adequate supervision

and assistance devices to prevent accidents.

(n) - Bed Rails. The facility must attempt to use

appropriate alternatives prior to installing a side or

bed rail. If a bed or side rail is used, the facility

must ensure correct installation, use, and

maintenance of bed rails, including but not limited

to the following elements.

(1) Assess the resident for risk of entrapment

from bed rails prior to installation.

(2) Review the risks and benefits of bed rails with

the resident or resident representative and obtain

informed consent prior to installation.

(3) Ensure that the bed’s dimensions are

appropriate for the resident’s size and weight.


by:

F 323 9/6/17

Based on records reviewed, observations. and

interviews, the facility failed to ensure side rails

were evaluated to ensure they were not an

entrapment hazard for 173 of 176 residents at the

facility who used side rails. On 07/31/17, an

Incident Report indicated Resident #5 was found,

by a Certified Nurse Aide (CNA) #4, entrapped

between the bed and the side rail. Three staff

members said they observed Resident #5's head

• A side rail assessment has been

completed for all residents who currently

utilize a side rail on their bed. Residents

will be reassessed for the use of side rails

on a quarterly basis, at any significant

change in condition and annually.

• An informed consent that includes the

risks and benefits for the use of side rails

has been reviewed and acknowledged


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was on the mattress, with the bottom bar of the


his/her body and his/her legs off the bed. CNA #2

said Resident #5 was "just hanging there", looked

"terrified", and he/she was holding onto the side

rail with both hands as if "holding on for dear life,"

or words to that effect. The facility took no

corrective action to evaluate the side rails used,

and 15 days later Resident #4, was observed by

four staff members dead and entrapped in the

rail, which was the same type of rail used by

Resident #5.

- The facility does not have records of any

assessments, evaluation of risk versus benefits,

and consents related to side rail use. Review of

Resident #4 and Resident #5's records indicated

no assessment for entrapment, risks or benefits

of side rail use, or consents were noted. The

Director of Nurses said that consents were not

obtained and no assessments were performed.

- The Facility was unable to provide any records

related to ensuring that the mattresses, beds, and

rails are being used per manufacture's

recommendations.

- The Facility had no preventative maintenance

records to ensure that measurements were

completed to ensure that the zones around the

side rails did not exceed the recommendations of

the FDA.

Findings include:

1. Resident #5 was admitted to the Facility in

February 2017 with diagnoses which included:

muscle weakness, dementia, and hypertension

(HTN).

with the resident and/or their legal

surrogate. If a change in the utilization of

side rail occurs, a revised informed

consent will be obtained.

• The facility has completed a bed,

mattress and side rail assessment for all

beds that have a side rail and has

determined that they are being used per

manufacturer’s recommendations.

• Any new beds, mattresses or side rails

that are utilized in the facility shall be

evaluated for safety prior to use.

• The facility has developed a supervision

and monitoring policy where residents are

monitored at least every two hours unless

otherwise indicated in the care plan.

Documentation of monitoring rounds will

be completed on the Supervision and

Monitoring of Residents Rounding Sheet.

• The facility has developed a preventative

maintenance audit tool and has measured

side rail zones to ensure they meet the

manufacturer’s recommendations.

• The Director of Maintenance and

maintenance staff has been in-serviced in

regards to the requirements to conduct

routine and effective preventative

maintenance that includes the

assessment of beds, mattresses and side

rails.

• The Director of Nursing or designee

shall be responsible to report any incident

that may constitute the potential for

serious harm or death to the Administrator

or designee upon identification of the

issue.

• The Director of Nursing has been

in-serviced to report any incident that may

constitute the potential for serious harm or


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A Resident ADL (Activity of Daily Living)/Daily

Care List, dated 02/10/17, indicated that Resident

#5 had a bed alarm in use, and required side rails

with bolsters (a long narrow cushion used for

support or as a barrier).

A Significant Change Minimum Data Set (MDS),

dated 06/07/17, indicated that Resident #5

required the extensive assistance of 2 or more

persons for bed mobility and transfers (how a

resident moves between surfaces, including to or

from a bed), and Resident #5 had moderate

cognitive impairment.

The Incident Investigation Report, dated

07/31/17, indicated that Resident #5 was found

by a CNA, "entrapped" between the bed and the

side rail. The report indicated that bolsters were

added to Resident #5's bed after the incident.

A Nurse's Note, dated 07/31/17 at 3:52 P.M.,

indicated that at 2:30 P.M., Resident #5 was

found stuck in-between his/her air mattress and

the left side rail of his/her bed. The note indicated

that staff was able to get Resident #5 unstuck

safely, and maintenance was paged to set up

bolsters and assess the side rails on his/her bed.


Certified Nurse Aide (CNA) #4 at 11:19 on

8/23/17. CNA #4 said that on 07/31/17 at

approximately 1:00 P.M., she assisted Resident

#5 into bed. CNA #4 said that approximately 45

minutes later, she walked by Resident #5's room

on her way to assist another resident and glanced

into Resident #5's room. CNA #4 said she

couldn't see Resident #5 in the bed, and so

entered the room to check on him/her. CNA #4

death to the Administrator or designee

upon identification of the issue.

• Staff has been in-serviced regarding

supervision, monitoring and accurate

direct reporting to the attending physician

and/or Medical Director of incidents that

may constitute the potential for serious

harm or death.

• The results of the individual bed rail

assessments, the informed consents for

bed rails, the preventative maintenance

safety logs regarding beds, mattresses

and side rails, along with the evaluations

of any new beds, mattresses and side

rails will be reported to the facility Quality

Assurance and Performance




been determined.

• The Administrator is responsible for the

completion and the ongoing compliance

with this individual plan of correction.


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said she observed Resident #5 with his/her head

on the mattress, the bottom of the side rail across

the front of his/her neck, and his/her legs off the

bed. CNA #4 said Resident #5 appeared tense

and nervous, but she and CNA #3 could not move

Resident #5 without choking him/her, so CNA#2

assisted them to move Resident #5 from under

the side rail and back into bed. CNA #4 said there

were no bolsters on Resident #5's bed at the time

of the incident, that they were not put in place

until afterwards.


at 9:34 A.M. on 8/23/17. CNA #3 said she heard

CNA #4 call for help, and when she responded,

she observed Resident #5 "hanging" from the

side rail and "holding on for dear life", or words to

that effect. CNA #3 said she and CNA #4 called

for more help because there was no way they

could have moved Resident #5 by themselves.

CNA #3 said she, CNA #2, and CNA #4 moved

Resident #5 from under the side rail and back

into bed.


at 9:00 A.M. on 8/23/17. CNA #2 said he heard a

CNA screaming for help and when he went into

Resident #5's room, he observed Resident #5's

head on his/her mattress with the bottom of the


his/her body hanging off the bed on the opposite

side of the rail. CNA #2 said Resident #5 was

holding on to the side rail with both hands as if

he/she was "hanging on for dear life", or words to

that effect. CNA #2 said Resident #5 was clearly

in distress and appeared "petrified." CNA #2 said

CNA #3 and CNA #4 were in Resident #5's room

trying to figure out how to get Resident #5's head

out from between the mattress and the side rail


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without hurting him/her. CNA #2 said one CNA

held the side rail to keep it still, another held

Resident #5's head still, and he picked up

Resident #5's body and tried to hold him/her as

flat as possible so they could slide his/her head

out and place him/her onto the bed.



Resident #5 did not have bolsters on his/her bed

at the time of the incident. This was not

consistent with the Resident ADL (Activity of Daily

Living)/Daily Care List.

Although Resident #5 had Bolsters added to the

bed, there was no indication that the beds of all

Residents with side rails were evaluated to

ensure that the distance between the mattress

and side rail was not large enough to allow

someone to become entrapped in the rail.


Maintenance Supervisor at 11:53 A.M. on

8/22/17. The Maintenance Supervisor said he

had not been made aware that Resident #5 was

entrapped between his/her mattress and side rail

and did not know if all the side rails in the Facility

were evaluated.

Surveyor #2 interviewed Unit Manager #1 at 9:20

A.M. on 08/22/17. Unit Manager #1 said bolsters

were not implemented on Resident #5's bed until

after he/she was caught under the side rail, as an

intervention to prevent him/her from getting too

close to the side rail because his/her bed was old,

or words to that effect.




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Director.


Administrator at 2:30 P.M. on 8/22/17. The

Administrator said he reviewed and signed all

incident reports personally, and incidents are

discussed in Morning Meeting, however after

reviewing his notes from Morning Meeting on

8/1/17, the day after Resident #5 was entrapped,

he said he did not have anything in his notes to

indicate that there was anything mentioned that

concerned him. The Administrator said he did not

pursue what "entrapped" meant, in reference to

Resident #5's incident report from 07/31/17.

A Risk Management/Quality Assurance

Confidential Report of Event form dated 7/31/17

indicated that Resident #5 had been found by a

CNA entrapped between the bed and mattress.

The Administrator's Signature section of the form

was blank.





Director.




she did not know of the incident with Resident #5

until it was briefly mentioned after Resident #4's

death on 8/15/17. The Medical Director said she

was not given any information about Resident #5

being entrapped in the side rail and she was on a

leave of absence and did not return until several


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days after it occurred. During the interview with

the Surveyors, the Medical Director reviewed

Resident #5's clinical record and observed a

progress note, dated 07/31/17, which indicated

that a voicemail was left for her regarding the

incident. The Medical Director said she did not

recall receiving any voicemail or other notification

about the incident.

The Medical Director said on 08/24/17 that she

still was not aware of the specifics of the 07/31/17

incident involving Resident #5, including the

position of Resident #5's body when he/she was

found by staff. The Medical Director said Facility

staff had not spoken with her about it, and she

had not seen the related incident report.



with diagnoses which included: hypertension,

dementia, and depression.




mobility, and the full staff performance of 2 or

more persons for transfers; and that Resident #4

had severe cognitive impairment.

CNA #2 said that on 08/15/17 between 7:00 A.M.

and 7:30 A.M., he observed Resident #4 lying in

bed on his/her left side, with his/her legs hanging

off of the bed from approximately mid-thigh down.

CNA #2 said Resident #4's head was twisted

sideways and to the right, in-between the bottom

of the side rail and the frame of the bed, and

his/her right hand was holding onto the side rail.

CNA #2 said he had to physically pull on the side


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rail in order for staff to "pry", or words to that

effect, Resident #4 out and reposition him/her on

the bed because Resident #4's head was under

the side rail and prevented them from being able

to lower the side rail. CNA #2 said that when

Resident #4 was repositioned in the bed, he

observed an indentation down the right side of


had been. CNA #2 said he told the Director of

Nurses (DON), on 08/15/17 or 08/16/17, how

Resident #4 was when he found him/her on

08/15/17.

CNA #3 said that on 08/15/17, she responded to

CNA #2's requests for help with Resident #4.

CNA #3 said that when she entered Resident #4's

room, she observed him/her lying in bed with


approximately mid-thigh down and his/her feet


head was twisted to the right and appeared to be

"stuck" between the mattress and the bottom of

the side rail, with a golf ball sized pool of saliva on

the floor under Resident #4's mouth. CNA #3 said

that in order to reposition Resident #4 onto the

bed, CNA #2 had to pull on the side rail so that

staff could free Resident #4's head because

his/her head prevented them from lowering the

side rail. CNA #3 said Resident #4 was obviously

deceased when she entered the room, that

his/her legs were cold to the touch and were

bluish in color.

CNA #4 said that on 08/15/17, she entered

Resident #4's room in response to CNA #2's

requests for help. CNA #4 said Resident #4

appeared deceased, that he/she was a "smoky

gray and blue in color", or words to that effect,

and had saliva running out of his/her mouth onto


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the floor. CNA #4 said Resident #4's head was

twisted to the right side, with his/her face was

between the bottom of the side rail and the

mattress, and the lower part of his/her body was

off of the bed. CNA #4 said the side rail had to be

physically pulled on to move it away from

Resident #4's face so that staff could reposition

him/her onto the bed. CNA #4 said she observed

a mark from the eye to the jawline, like an

indentation, consistent with where the bottom of

the side rail had been on his/her face.



on 08/15/17, she observed Resident #4 in bed

with his/her legs hanging off of the bed and

his/her face "stuck" in the side rail. Nurse #2 said

Resident #4's face from just behind the eyes

forward was protruding beyond the side rail, with

the bar from the side rail running along his/her

face. Nurse #2 said Resident #4's face appeared

swollen, his/her lips cyanotic, with saliva running

out of his/her mouth, and his/her legs were blue

in color and mottled (irregular patches of skin

discoloration as a result of diminished circulation).





the bed because the position of Resident #4's

head prevented staff from being able to lower the

side rail. Nurse #2 said it still took effort to free

Resident #4's head from between the bed frame

and bottom of the side rail. Nurse #2 said she

called the Medical Director, and informed her that


face in the side rail. Nurse #2 said she informed

the DON that staff found Resident #4 with his/her

face under the side rail.


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The Medical Director said she was told that

Resident #4 was found pulseless and had passed

away but it wasn't until 08/17/17 or 08/18/17 that

staff told her Resident #4's head had been

trapped in the side rail and that staff was

concerned that the use of side rails contributed to

Resident #4's death.

The Maintenance Request, dated 07/31/17,

indicated that Resident #5's side rail was very

loose and needed bolsters as soon as possible.

3. There was no documentation at the time of

survey of assessments for the use of side rails for

Resident #4 or Resident #5, or that Resident #5

was reassessed following an alleged incident of

entrapment in the side rail on 07/31/17.

Surveyor #2 interviewed Unit Manager #1 at 9:20

A.M. on 08/22/17. Unit Manager #1 said side rail

assessments were completed at the time of a

resident's admission to the Facility, and if the

resident requested side rails.


DON at 3:12 P.M. on 8/22/17. The DON said that

all resident related assessments were to be

completed by licensed nurses according to the

MDS schedule. The DON said the Facility used a

Safety/Restraint Assessment, but that this

assessment was not an assessment for the use

of side rails. The DON said the Facility did not

have an assessment for the use of side rails.

The DON said, as of 8/24/17, Resident #5 still

had side rails in use but they added bolsters to

block the gap where Resident #5 got his/her neck

caught.


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4. Surveyor #1 and Surveyor #2 interviewed the


8/22/17. The Maintenance Supervisor said the

Facility's resident beds were of varying brands

and models, and side rails were attached at the

request of nursing. The Maintenance Supervisor

said he did not know if the side rails were

recommended for use with the brands and

models of beds used by the Facility, and was

unable to find the manufacturer's specifications

for the use of the side rails, or the type of bed

used by Resident #4 and Resident #5. The

Maintenance Supervisor said his department

used a computer program to schedule checks of

the side rails, but could not recall how often or

when the last checks were completed. The

Maintenance Supervisor was later able to provide

documentation of the side rail checks for

Resident #4's and Resident #5's unit, which was

dated 05/26/17.

The MicroAir User Manual for the air mattress in

use for Resident #4 included a warning that

indicated; "Patient entrapment with bed side rails

may cause injury or death and the mattress must

fit the bed frame and side rails snugly to prevent

patient entrapment. Follow the manufacturer's

instructions. Monitor patient frequently. Read and

understand the Owner's/Operator's Manual prior

to using this equipment. Proper patient

assessment, monitoring, maintenance and use of

equipment is required to reduce the risk of

entrapment. Variations in bed rail dimensions,

mattress thickness, size or density could increase

the risk of entrapment". The manual provided

links to the Food and Drug Administration (FDA)

website and another site published by the

Hospital Bed Safety Workgroup.


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The "Hospital Bed System Dimensional and

Assessment Guidance to Reduce Entrapment",

issued by the FDA 3/10/06, recommended that

the limit measured between the mattress support

platform and the lowest portion of the side rail

was 2 3/8 inches and the gap that forms between

the mattress compressed by the patient and the

lowermost portion of the side rail, should be less

than 2 3/8 inches.

Surveyor #1 and Surveyor #2 accompanied the

Maintenance Supervisor to obtain measurements

of the bed model that was in use for Resident #4

and Resident #5 at the time of the incidents. The

measurement from the mattress support platform

and the lowest portion of the side rail 7.0 inches.

The measurement from the mattress to the

bottom of the side rail was 2.5 inches with no

compression of the mattress. Both

measurements were in excess of the FDA

measurement recommendations.

Surveyor #2 interviewed the Customer Service

Representative at 10:17 A.M. on 08/24/17. The

Customer Service Representative said that model

of bed had not been manufactured since prior to

2009. The Customer Service Representative said

the replacement parts for that model of bed were

also no longer being manufactured or sold, and

hadn't been for approximately the same length of

time.

The DON said she checked the Facility's paper

and online policies, and the Facility did not have a

policy and procedure in place on the use and

implementation of resident side rails.

Unit Manager #1 said the Facility's policy for side

rail use was that if the side rails were needed for


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positioning or enabling movement, then they were

utilized.

The DON said staff did not obtain consent for the

use of the side rails, and she did not know why.

There was no documentation at the time of

survey that Resident #4 and Resident #5 had

consents in place, or a review of the risks and

benefits, for the use of side rails.

F 461

SS=L

Various sections in 483.10,483.25,483.90

BEDROOMS - WINDOW/FLOOR,

BED/FURNITURE/CLOSET

483.10

(i)(4) Private closet space in each resident room,

as specified in §483.90(e)(2)(iv);

483.25

(n)(4) Follow the manufacturers’

recommendations and specifications for installing

and maintaining bed rails.

483.90

(c)(3) Conduct Regular inspection of all bed

frames, mattresses, and bed rails, if any, as part

of a regular maintenance program to identify

areas of possible entrapment. When bed rails

and mattresses are used and purchased

separately from the bed frame, the facility must

ensure that the bed rails, mattress, and bed

frame are compatible.

(e)(1)(vi) - Resident Rooms

Bedrooms must --

(vi) - Have at least one window to the outside; and

F 461 9/6/17


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(vii) Have a floor at or above grade level.

(e)(2) -The facility must provide each resident

with--

(i) A separate bed of proper size and height for

the safety and convenience of the resident;

(ii) A clean, comfortable mattress;

(iii) Bedding, appropriate to the weather and

climate; and

(iv) Functional furniture appropriate to the

resident’s needs, and individual closet space in

the resident’s bedroom with clothes racks and

shelves accessible to the resident.


by:

Based on records reviewed and interviews, the

facility failed to ensure the installation and

maintenance of side rails was conducted in

accordance with manufacturer's

recommendations and specifications. The facility

failed to conduct regular inspections of side rails

in an attempt to identify areas of possible

entrapment. The facility failed to ensure that side

rails, mattresses, and bed frames were

compatible.

- On 08/22/17, the Facility provided

documentation which indicated that 173 of 176

residents in the Facility had side rails on their

beds.

- On 07/31/17, an Incident Report indicated

Resident #5 was found, by a Certified Nurse Aide

(CNA) #4, entrapped between the bed and the

side rail. CNA #2 said he observed Resident #5's

• The facility has conducted an inspection

of all beds with side rails and has

determined that the beds, mattresses and

side rail are compatible and installed and

maintained within manufacturer’s

recommendations and specifications.

• All new beds, mattresses and side rails

will be evaluated for safety prior to use in

the facility. Documentation of all new bed,

mattress and side rail evaluations will be

maintained and presented to the facility

Quality Assurance and Performance




been determined.

• All existing beds with side rails will be

inspected on a quarterly basis for safety.

Any bed, mattress and/or side rail issue

that pose a safety risk will be tagged and


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body to be outside the bed with his/her head on

the bed with the bottom of the side rail across

his/her neck and Resident #5 was "just hanging

there", looked "terrified", and he/she was holding

onto the side rail with both hands as if "holding on

for dear life", or words to that effect.

There was no documentation at the time of

survey that Resident #5 was assessed for the use

of side rails before installation, or after the

incident. There was no documentation at the time

of survey of any consent by Resident #5 or

his/her representative for the use of side rails.

There was no documentation at the time of the

survey to indicate that the Facility determined that

the side rails were compatable for use on the bed

or that they were inspected to ensure they were a

safe distance from the frame and mattress.





CAN #2 said that the side rail had to be physically



the bed. Resident #4's face was observed to be

swollen and his/her lips were cyanotic (a bluish

discoloration of the skin due to low levels of

oxygen in the blood), and an indentation from the

bottom bar of the side rail was observed running

partway down Resident #4's face. Resident #4

was determined to be deceased.

There was no indication at the time of the survey

that all residents' beds were evaluated to ensure

that side rails did not pose a risk of entrapment.

removed from service until corrective

measures can be applied. Documentation

of the inspections and any safety issues

will be presented to the Safety Committee

and the Quality Assurance and

Performance Improvement Committee on

a monthly basis for one year and then

quarterly thereafter until substantial

compliance has been determined.

• Staff has been in-serviced and

demonstrated understanding of the

facility’s policy regarding the management

of resident care equipment.

• The Director of Plant Operations and

Maintenance is responsible for the

completion and the ongoing compliance

with this individual plan of correction.


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Findings include:



8/22/17. The Maintenance Supervisor said the

Facility's resident beds were of varying brands

and models, and side rails were attached at the

request of nursing. The Maintenance Supervisor

said he did not know if the side rails were

recommended for use with the brands and

models of beds used by the Facility.

The Maintenance Supervisor said he was unable

to find the manufacturer's recommendations and

specifications for use of the side rails, or the type

of bed used by Resident #4 and Resident #5. The

Maintenance Supervisor said his department

used a computer program to schedule checks of

the side rails, but could not recall how often the

checks were completed, or when the last checks

were completed. The Maintenance Supervisor

was later able to provide documentation of the

side rail checks for Resident #4's and Resident

#5's unit, which was dated 05/26/17.


Director of Nurses (DON) at 3:12 P.M. on

8/22/17. The DON said she did not know how

often the side rails were checked, as checks were

done by maintenance.


#2 at 10:15 A.M. on 8/22/17. Nurse #2 said she

did not know if there were scheduled

maintenance checks for the side rails.

The Maintenance Request, dated 07/31/17,

indicated that Resident #5's side rail was very

loose and needed bolsters as soon as possible.


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The MicroAir User Manual for the air mattress in

use for Resident #4 included a warning that

indicated; "Patient entrapment with bed side rails

may cause injury or death and the mattress must

fit the bed frame and side rails snugly to prevent

patient entrapment. Follow the manufacturer's

instructions. Monitor patient frequently. Read and

understand the Owner's/Operator's Manual prior

to using this equipment. Proper patient

assessment, monitoring, maintenance and use of

equipment is required to reduce the risk of

entrapment. Variations in bed rail dimensions,

mattress thickness, size or density could increase

the risk of entrapment". The manual provided

links to the Food and Drug Administration (FDA)

website and another site published by the

Hospital Bed Safety Workgroup.

The "Hospital Bed System Dimensional and

Assessment Guidance to Reduce Entrapment",

issued by the FDA 3/10/06, recommended that

the limit measured between the mattress support

platform and the lowest portion of the side rail

was 2 3/8 inches and the gap that forms between

the mattress compressed by the patient and the

lowermost portion of the side rail, should be less

than 2 3/8 inches.

Surveyor #1 and Surveyor #2 accompanied the

Maintenance Supervisor to obtain measurements

of the bed model that was in use for Resident #4

and Resident #5 at the time of the incidents. The

measurement from the mattress support platform

and the lowest portion of the side rail 7.0 inches.

The measurement from the mattress to the

bottom of the side rail was 2.5 inches with no

compression of the mattress. Both

measurements were in excess of the FDA


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measurement recommendations.

Surveyor #2 interviewed the Customer Service

Representative at 10:17 A.M. on 08/24/17. The

Customer Service Representative said that model

of bed had not been manufactured since prior to

2009. The Customer Service Representative said

the replacement parts for the model of bed were

also no longer being manufactured or sold, and

hadn't been for approximately the same length of

time.


Documents

PRINTED: 09/06/2017 DEPARTMENT OF HEALTH AND · PDF filea. building _____ (x1) provider/supplier/clia identification number: statement of deficiencies and plan of correction (x3) date