|§483.10(i)(4) Private closet space in each resident room, as specified in §483.90|
§483.90(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.
§483.90(e)(3) CMS, or in the case of a nursing facility the survey agency, may permit variations in requirements specified in paragraphs (e)(1) (i) and (ii) of this section relating to rooms in individual cases when the facility demonstrates in writing that the variations
(i) Are in accordance with the special needs of the residents; and
(ii) Will not adversely affect residents' health and safety.
Based on review of clinical records and the facility's investigation documents, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents had a proper size bed for one of 17 residents reviewed (Resident 1).
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 5, 2019, revealed that the resident required extensive assistance with bed mobility and was 69 inches tall and weighed 237 pounds. A nursing note, dated February 7, 2020, revealed that Resident 1 was re-admitted to the facility from the hospital, and a baseline care plan, dated February 7, 2020, indicated that the resident had a history of falls, required the assistance of one staff with bed mobility, and did not have an air mattress on his bed.
A bed safety evaluation for Resident 1, dated February 7, 2020, revealed that the resident had a standard size bed; the resident's size, weight or height were inappropriate for the size of the bed; and the resident's bed width was inappropriate for the resident to turn and reposition.
There was no documented evidence that the resident was provided with a bed that was appropriate for his size and needs.
Facility investigation documents, dated February 10, 2020, at 6:45 a.m. revealed that Nurse Aide 1 went to change Resident 1's sheets and when she rolled him away from her, his lower body slipped off of the bed.
Observations on February 11, 2020, at 4:42 p.m. revealed that Resident 1's bed was a standard size.
Interview with the Director of Nursing on February 11, 2020, at 6:09 p.m. confirmed that larger beds were available for residents and Resident 1 had a standard size bed.
28 Pa. Code 211.12(d)(5) Nursing services.
| ||Plan of Correction - To be completed: 03/24/2020|
The following is being submitted for plan of correction purposes only and should not be construed as an admission.
1- Resident 1 no longer resides in facility.
2- Current residents bed safety evaluations were reviewed for accuracy by restorative nurse.
3- Education of F917 with licensed staff with a focus on ensuring the resident(s) is/are provided equipment that is appropriate for their needs and documented on their bed safety evaluation form.
4- Bed safety evaluations will be completed upon admission/readmission, quarterly, with falls and change in equipment. A random audit will be performed by wound care coordinator or designee on new admissions/readmission and any change in mattress equipment- daily x 2 weeks then weekly x 2 and monthly.
5- Results of monitoring will be reported to the Quality Assurance Performance Improvement Committee.