|§483.10(e) Respect and Dignity. |
The resident has a right to be treated with respect and dignity, including:
§483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2).
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.
§483.12(a) The facility must-
§483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.
Based on observations and clinical record review it was determined that the facility failed to ensure that residents were free of chemical restraints for one (Resident 1) out of six residents reviewed.
A review of Resident 1's clinical record revealed that on March 2, 2019, the resident was restless, screaming and attempting to hit staff. The staff offered the resident a snack, back massage and wheeled the resident around the unit, but the resident's behaviors continued. Physician's order was received for Ativan Gel 0.5 mg/ml (an antianxiety medication) every eight hours as needed for a duration of seven days for anxiety and a psychiatric evaluation.
A review of nursing progress notes revealed that the resident was combative during the 11 PM to 7 AM shift on April 1, 2019. Staff described the resident as yelling and trying to hit staff as the resident believed the staff stole her baby.
During the 7 AM to 3 PM on April 1, 2019, the resident was roaming the hallways attempting to go home to look for her baby according to nursing documentation. The resident became aggressive with staff redirection. At 11:15 a.m., the resident left the facility undetected by the staff. The resident's attending physician was contacted and ordered Ativan gel 0.5 mg every eight hours as needed for anxiety. 15 minute checks and then one to one observations were also ordered.
It was noted that on April 2, 2019, the resident was involved in an altercation with two other residents.
A physician order was noted on April 2, 2019, to change the Ativan gel from 0.5 mg every eight hours for anxiety to Ativan 1 mg every eight hours for anxiety. Seroquel 25 mg (an antipsychotic drug used to treat certain mental/mood conditions such as schizophrenia, bipolar disorder, sudden episodes of mania or depression associated with bipolar disorder) at bedtime was added to the resident's medication regimen.
Potential side effects of both Ativan and Seroquel are drowsiness and tiredness.
Further review of the resident's clinical record revealed that the interdisciplinary team met on April 11, 2019, to discuss the resident's behaviors and incidents of resident to resident aggression. However, no additional non-pharmacological interventions were devised or implemented at that time to manage or mitigate the resident's behaviors.
A review of interdisciplinary progress notes dated April 21, 2019, revealed that the resident was involved in a resident to resident altercation, in which she was the victim.
A physician order was noted to change the resident's to Ativan 1 mg twice daily and the Seroquel was changed to 25 mg twice daily on April 22, 2019.
A review of progress notes revealed that the resident's evening medications were held on April 27, 2019, because the resident was asleep/lethargic the entire shift.
On April 30, 2019, staff noted that the resident was very sleepy, unable to take evening medications or follow directions. All medications were held and despite encouragement the resident could not wake up to eat her eveing meal.
On May 2, 2019, all the resident's medications were held because the resident was lethargic/sleepy on the 3 PM to 11 PM shift. On May 5, 2019, staff documented at 16:41 (4:41 PM) that the resident remained asleep, was unable to comply with taking medications and refused meals. At 21:43 (9:43 PM) staff documented that all medications were held because the resident was lethargic/asleep and refused meals.
On May 8, 2019, the resident's Ativan was held on the 3 PM to 11 PM shift, because the resident was asleep. Progress notes noted during the 3 PM to 11 PM shift on May 12, 2019, revealed that the resident was asleep the entire shift without waking up. She was unable to take her ordered medications or eat her meal as each time she opened her eyes she immediately closed them.
There was no indication that the facility had developed and consistently attempted individualized alternative interventions to manage or mitigate the resident's anxious/agitated behaviors, even after the resident displayed potential adverse side effects of psychoactive drug use, which negatively affected her activities of daily living. The facility staff administered the psychotropic drugs, Ativan and Seroquel to most readily control the resident's behavior with the least amount of staff effort.
28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing Services
previously cited: 2/22/19, 8/17/18
28 Pa. Code 211.8 (b) Use of restraints
28 Pa. Code 211.9(a)(1) Pharmacy services
28 Pa. Code 211.2(a) Physician Services
| ||Plan of Correction - To be completed: 06/21/2019|
Preparation and submission of this
Plan of Correction does not
constitute admission for purposes of
general liability, professional
malpractice or any other court
F Tag 605
- Resident 1 was seen and evaluated by psych and medications were reviewed. GDR was done. Resident 1 has no further episodes of agitation or exit seeking. Her condition is stable.
- Residents receiving psychotropic medications will be assessed to ensure they are not chemically restrained.
- Staff Educator will re-educate licensed staff to identify changes in behaviors of residents using psychotropic medications. The focus being on a decrease in activities of daily living, and implement individualized alternative interventions to manage the resident's behavior.
- Audits will be conducted by Manager/designee of 5 residents using psychotropic medications weekly times 4 weeks, then 5 residents weekly times 2 weeks, then 5 residents monthly times 2 months.
Variances will be addressed as identified. Results will be reported to QAPI committee for review.