State Operations Manual - Accidents

Below physical and chemical restraints I found accidents in the CMS State Operations Manual. All three are cross-referenced and bound together with falls. Again you get a feeling of the liability shadow; as all falls are not just falls. Just as with physical and chemical restraints, the natural increase in falls with aging must be separated from accidents as well as from restraints and non-restraints.

(p 302) "Accident" refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. . . .

"Avoidable Accident" means that an accident occurred because the facility failed to:
Identify environmental hazards and/or assess individual risk of an accident, including the need for supervision and/or assistive device; and/or
Evaluate/analyze the hazards and risks and eliminate them, if possible, or, if not possible; identify and implement measures to reduce the hazards/risk as much as possible; . . .

(p 303) "Unavoidable Accident" means that an accident occurred despite sufficient and comprehensive facility systems designed and implemented to:
Identify environmental hazards and individual resident risk of an accident, including the need for supervision; . . .

"Assistive Device" refers to any item (e.g., fixtures such as handrails, grab bars, and mechanical devices/equipment such as stand-alone or overhead transfer lifts, canes, wheelchairs, and walkers, etc.) that is used by, or in the care of a resident to promote, supplement, or enhance the resident's function and/or safety.

"Environment" refers to any environment or area in the facility that is frequented by or accessible to residents, . . .

"Fall" refers to unintentionally coming to rest on the ground, floor, or other lower level, . . .

"Hazards" refer to elements of the resident environment that have the potential to cause injury or illness.

• "Hazards over which the facility has control" are those hazards in the resident environment where reasonable efforts by the facility could influence the risk for resulting injury or illness.
• (p 304) "Free of accident hazards as possible" refers to being free of accident hazards over which the facility has control.

"Risks" refers to any external factor, facility characteristic (e.g., staffing or physical environment) or characteristic of an individual resident that influences the likelihood of an accident. [The higher the risk, the less profitable a facility can be expected to be.]

"Supervision/Adequate Supervision" refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level of supervision and number of staff required, the competency and training of the staff, and the frequency of supervision needed. This determination is based on the individual resident's assessed needs and identified hazards in the resident environment. Adequate supervision my vary from resident to resident and from time to time for the same resident.

[Margaret was safe and secure in her wheelchair all day (10 Feb) in the public areas of memory care until we brought her to our apartment. She hit the floor within 30 minutes on two falls with me watching. One potential fall was avoided by me running for help in time to avoid it.  It took two caregivers to put her back each time. We fastened the lap belt and had no more problem as she played with her keepsakes and I continued writing.]

(p 309) The interventions listed below include supervision and other actions that could address potential or actual negative interactions.

• Evaluating staffing levels to ensure adequate supervision (if it is adequate, it is meeting the resident's needs) . . .
• Evaluating staffing assignments to ensure consistent staff who are more familiar with the resident and who thus may be able to identify changes in a resident's condition and behavior;
• Providing safe supervised areas for unrestricted movement.

(p 311) NOTE: Challenging a resident's balance and training him/her to recover from loss of balance is an intentional therapeutic intervention. The losses of balance that occur during supervised therapeutic interventions are not considered a fall.


(P312) NOTE; A fall by a resident does not necessarily indicate a deficient practice because not every fall can be avoided.

Margaret cannot operate the lap belt release button as installed. I will reinstall it with the ends reversed so she may be able to use her left hand (making it a non-restraint). We need the lap belt in our apartment as she fell even with me watching ever couple of minutes.

Her fall in the patio area is also left unsettled. As are the corrections needed to prevent another resident being driven into the iron fence with the possibility of greater injuries, or if she gains access to the tilted endless path on the patio in her wheelchair before she can use her hands to brake.

    https://residentialcarefortwo.blogspot.com/2018/11/memory-care-patio-monitoring.html

      https://residentialcarefortwo.blogspot.com/2018/11/sloped-lawn.html

These three State Operations Manual excerpts point out the need for adequate resident supervision to reduce the risks of profitably operating a long term care facility including memory care.

For Missouri, Title 19--Department of Health and Human Services, Division30--Division of Health Standards and Licensure, Chapter 85--Intermediate Care and Skilled Nursing Facility, construction standards . . .  include:

19 CSR 30-85.012(2) . . . The facility shall prepare and submit working drawings and specification, complete in all respects, for approval by the division. These plans shall cover all phases of the construction project, including site preparation; paving; general construction; . . .


The sloped lawn hazard seems to have evaded the architect, the State, the City, and the annual HHS inspection as well as Provision Living at Columbia. 

State Operations Manual - Chemical Restraints

Chemical Restraints

Researching how to keep Margaret in her wheelchair now that she is again active landed me in the area of mechanical restraints. It is followed by chemical restraint. We know what that means.

We spent a couple of months In skilled-nursing, in the nursing home my mother stayed at over 20 years ago, while our apartment area was rebuilt after a flood. Xanax was administered to keep Margaret “calm” by the house doctor’s order. We first saw a frightening chance in her personality (she sort of disappeared) followed by six falls as she slowly adjusted to the dosage two years ago. https://residentialcarefortwo.blogspot.com/2017/02/fall-number-six.html

This past year Xanax has been continued on a PRN basis at a minimal dosage. It then increased.  Is the current dosage a chemical restraint? Memory care substitutes time to redirect and distract in place of using “calming” medications.  

The first two of seven purchases were for one pill a day to be used as needed. The other five were for two pills per day and/or as needed. 

Factoring in the time each purchase lasted yields the average number of pills per day. The facility never used the maximum rate the doctor ordered of two pills per day for the entire lot of 30 or 60 pills.

Medical records would show why the dosage was changed from one to two pills; and in spite of this, the average dosage was about the same for the first and last purchases. 

During the time of maximum use, Margaret had three falls that took her to the emergency room. The regulations require massive documentation to determine if the usage was for a medical condition or for the convenience of under trained and inexperienced caregivers. Our insurance company sent us a note at the first of the year cautioning us about the use of Xanax for elderly persons.

(p 124) Determination of Indication for Medication Use   The clinical record must reflect the following: 

•         Whether an excessive dose and/or duration of the medication was administered to the resident;
•        Whether there is adequate monitoring for the effectiveness of the medication in treating the specific condition and for any adverse consequences resulting from the medication; . . .

Risks and Psychosocial Impacts Related to Use of Chemical Restraints   A medication that is used for discipline or convenience and is not required to treat medical symptoms, may cause the resident to be: [We experienced this in our two months in skilled nursing.]

• Subdued, sedated, or withdrawn; [One pupil much larger than the other.]
•  Asleep during hours that he/she would not ordinarily be asleep; or
•  Limited in his/her functional capacity. [A blank face with a stare into the distance.] . . .

Additional effects . . .

•        Decline in physical functioning including an increased dependence in activities of daily living (e.g., ability to walk), impaired muscle strength and balance, decline in range of motion, and risk for development contractures, increased risk of falls; and . . .

(p 125) Facilities are responsible for knowing the effects medications have on their residents. Even if a medication was initially administered for a medical symptom, the continued administration of a medication in the absence of a medical symptom, that sedates a resident or otherwise makes it easier to care for them, is a chemical restraint. Other examples . . .

•         Staff have recommended to the practitioner that a resident be administered a medication in order to prevent a resident from displaying behaviors . . .
•        Staff become upset with a resident who resists receiving a bath and pinches staff. [Or hits with some strength going into the shower. A San Antonio 16-bed facility had no apartment showers; only a well heated showerroom the residents liked to use.]

(p 127) Interview direct care staff and/or licensed personnel (e.g., nursing, social workers), as appropriate, on various shifts that provide care to the resident to determine: (7 of 11)                 

•      Why the medication is being administered and what effect (physical and/or psychosocial) it has on the resident; . . .
•    ·   Depending on whether distressed behavior is expressed, how do staff respond and what individualized, person-centered interventions are attempted; . . . 
• 
  
•                [Pacing the “1, 2, 3, Stand” count to Margaret’s body language. Stand comes at the point where she is willing and ready to stand (0 seconds to 5 minutes).]
•           [Strong hits are referred to as “Love taps.”]
•                [Avoid any negative statement or comment that suggests that Margaret will be prepared to respond in kind. ]
•             [Ask questions in our apartment, and of others, after being absent several days.]
•               [Leave on toilet long enough to be effective (5 to 15 minutes (work on something else and come back).] [Margaret is classified as a “two-person assist resident” for the protection of her and her caregivers based on her weight.]
•               [Either put her to bed by 8:00 pm or get her ready any time after the evening meal and then let her watch TV so she is not overly tired when changing for bed.]
• 
  
•       Who and how the facility monitors for adverse consequences related to the administration of the medication; . . . 
•       How is it determined that the medical symptom is no longer present and who determines this; . . .  [A PRN time-limited basis may or may not be a restraint.] 
•       How staff are assigned to monitor, care for, and be familiar with residents’ behaviors (e.g., the number, location, and consistency of staff assigned across different shifts/units); . . . [Rate of rotation of staff among three assisted living floors and two memory care floors.]
•      Who supervises the overall delivery of care to the residents to assure care planned interventions are implemented and supervision occurs (to assure that a chemical restraint is not being used for staff convenience); and
•       Whether staff have discussed concerns with the Director of Nurses and Administrator regarding the behavioral symptoms of specific residents and the monitoring of intervention, and whether staff have requested more resources or changes to resident assignments, and the response to the concerns.

With all of the above in mind, the use of Xanax can be examined. Originally this post was scheduled for after the first year of medication: How do family members monitor the use of drugs independently from the facility records. The misuse of drugs has been a common practice in long term care. Provision Living contracted with a bubble pack supplier who both delivers the medications and monitors daily use over the Internet (for about $600 per year for us, but we were not accepted). 

Our stay in skilled-nursing was another learning experience about what I would now call a chemical restraint. In two weeks we will meet with our neurologist to review “calming drugs” used for the past year and the state of her hands after her concussion last summer.

The year started with a letter from our health insurance HMO warning us about the risk of falling with use of Xanax in elderly people. I was assured that this was not a problem as it was being used at the minimum dosage and on an as needed basis. The chart shows the dosage was doubled after the first month. Currently the dosage is one pill AM and PM, and another as needed.

To my knowledge, until several of the above questions are answered, there is no way to know if current use represents a restraint or a non-restraint. Or at times it is one or the other?

What we do know is that Margaret has become active this week to the point everyone is commenting about the “old days” before the concussion. This creates problems. She is now falling (sliding) out of stuffed chairs as well as out of the wheelchair. 

She is permitted to have the wheelchair brakes unlocked when I am in the dining and activity area to watch her. She can move about at the table and return without someone pushing her back in place every few minutes with the brakes locked (restrained). She is free to roam again (by walking the wheelchair, as she cannot use her hands); when she is not being restrained in front of the wall TV screen. [Rumor has it that the new owners are hiring a new memory care director of activities.] 

State Operations Manual - Physical Restraints

[I have extracted signal sentences from six pages related to restraints used in long term care facilities in Missouri. See previous post for photos of our wheelchair and the decision of using a restraint or other alternatives to keep Margaret from sliding out of the wheelchair. Bolding and underling have been added for quick review.]

483.12(a)(2) 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-evaluations of the need for restraints. (p 110)

DEFINITIONS “Physical restraint” is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria:

•              Is attached or adjacent to the resident’ body;
•              Cannot be removed easily by the resident; and
•              Restricts the resident’s freedom of movement or normal access to his/her body.

“Removes easily” means that the manual method, physical or mechanical device, equipment, or material, can be removed intentionally by the resident in the same manner as it was applied by the staff. (p 111)

Assessment, Care Planning, and Documentation for the Use of a Physical Restraint . . . There must be documentation identifying the medical symptom being treated and an order for the use of the specific type of restraint. However, the practitioner’s order alone (without supporting clinical documentation) is not sufficient to warrant the use of restrictions. The facility is accountable for the process to meet the minimum requirements of the regulation including appropriate assessment, care planning by the interdisciplinary team, and documentation of the medical symptoms and use of the physical restraint for the least amount of time possible and provide ongoing re-evaluation. (p 112)

Also, a resident, or the resident representative, has the right to refuse treatment; however, he/she does not have the right to demand a restraint be used when it is not necessary to treat a medical condition. (p 113)

Facilities are responsible for knowing the effects devices have on its residents.

The use of a restraint must be individualized and be based upon the resident’s condition and medical symptoms that must be treated. While a physical restraint may be used to treat an identified medical symptom for one resident, the use of the same type of restraint may not be appropriate to treat other residents with the same medical symptoms.

. . . for concerns related to ensuring the resident receives adequate supervision to prevent accidents).

NOTE: Falls do not constitute self-injurious behavior or a medical symptom that warrants the use of physical restraint. (p 114)

Reasons for using restraints for staff convenience or discipline may include:

•      . . . too busy to monitor the resident, and their workload includes too many residents to provide monitoring.
•      . . . not enough staff . . .
•      . . . new staff and/or temporary staff do not know the resident, how to approach, and/or how to address behavioral symptoms or care needs . . . [How to slow down, read memory care resident’s body language, and provide the time needed for a resident to respond to well-spaced commands for Margaret.]
•      Lack of staff education . . .
•      In response to a resident’s wandering behavior . . .  [Margaret is free to wander in memory care, but not to open a door to other apartments, in general.]

[Short term understaffing seems to be acceptable: “high activity times.” Failure to plan for this is the problem.] (p 115)

NOTE: . . . For safety reasons, do not request that the resident remove the restraint, but rather, request that staff ask the resident to demonstrate how he/she releases the device without staff providing specific instructions for the removal. . . . Additionally, falls that occur while a person is physically restrained often result in more severe injuries (e.g., strangulation, entrapment. (p 117)

KEY ELEMENTS OF NONCOMPLIANCE To cite deficient practice at F604, the surveyor’s investigation will generally show that the facility has failed, in one or more areas, to do any one or more of the following:

• ·     Ensure that the resident is free from physical restraints imposed for discipline or staff convenience.
• ·     Identify the medical symptom being treated when using a device or a facility practice that meets the definition of physical restraint.
• ·     Define and implement interventions according to standards of practice during the use of a physical restraint that is used for treatment of a medical symptom.
• ·     Provide the least restrictive restraint for the least time possible.
• ·     Providing ongoing monitoring and evaluation for the continued use [and of the current] use of a physical restraint to treat a medical symptom; or
• ·     Develop and implement interventions for reducing or eventually discontinuing the use of the restraint when no longer required to treat a resident’s medical symptoms. (p 118

MY COMMENTS: The wheelchair then turns out to be a hazardous restraint for memory care residents. When I started to get out of the rental wheelchair at the store several people yelled, “Lock the brakes”. 

These rules reflect a concern by the powers that influence long term care to take the doctor and the facility out of range of liability claims when operating with "best practices" in relation to falls. Restraints are not to be used to prevent (occasional) falls. 

At some point a resident can be restricted to use a cane or a walker. At another point the resident is restricted to a wheelchair. Then restricted to a transfer chair. And finally to bed.

As a customary practice they are acceptable. The frequency and number of falls seems to be of importance in making the transitions; with the doctor and facility not liable for acceptable falls. 

All falls cannot be prevented. Excessive falls and accidental falls are to be avoided. Chemical restraints can also increase the rate of falling.

Wheelchair Experiences

The TV Club

Actual experience gets us closer to the truth of the matter. We were discussing seat belts and lap belts; and how to keep Maggie safe and secure in her present active state; while standing in the dining area.

Maggie was seated at the far end of the TV Club row in a chair just like the one at this end. At least three caregivers  were able to see her. Her head was a bit lower than some of the others. When I walked over toward her, to get her wheelchair, I noticed she was not only a bit lower but also forward of the others. She was sitting on the floor!

All this happened unobserved behind the shield of people and chairs. Falls do happen. This was a slide, not  a fall; but anyone on the floor "got there by a fall" requires a report and vitals. I have no picture, in part, as pictures are not encouranged and my phone ran out of space on the spot.

Tilting Recreation

 So imagine sliding out while leaning back as far as you can. That lands you a couple of feet in front of the chair. Caregivers place Maggie at the end away from another lady who also can be a bit aggressive given the right circumstances. It is good for both of them to be out of their wheelchairs.

A person can overreach and tumble out of a wheelchair but the most common exit is to lean back and slide down the front for Maggie. This does little damage unless you twist and catch your side on parts of the wheelchair. The result is a bump or a long one inch wide bruise that heals in three to five days.

We got Maggie into a "safe" seat and then practiced letting me slide out of a lap belt.

Both Safely Seated, Belt Down

Relaxed with Belt Sliding Up

The Ride Begins

Under the Arms

Under the Chin

Believe me, this was not staged. It was only when I put these photos together that I realized that Maggie was mimicking what we were doing. I did not know she was even in the pictures.

[Coincidences, highly unexpected events, are fairly common in memory care and in religion.]

At any rate I leave it to you, what the next picture would be. Maggie would be sitting out in front  of her chair. I would end up strangled, entangled, dangling, with a wrenched back, or with a bump on the back of my head. We forgot to get a pillow just in case bad went to worse. Taking  the next picture did not seem a good idea with the other residents present.

Several days have passed. Maggie seems to be aware of our concerns. She has not fallen. She can boost herself back into the seat of the wheelchair. She can stand up, when she wants to, all by herself, but needs assistance walking. She can use her walker again as the occupational therapy is working on her right hand.

In the 10:00 am fitness class, the idea that walkers for elderly could be designed the same as children's walkers. Just a bit bigger. Belts with a groin strap and circular walls are restraining but provide the freedom for needed exercise.

Thank you to the caregiver who took the time to hold the camera in one spot long enough to get this remarkable set of pictures.

Conclusion: Wheelchairs are dangerous things, like bicycles, Kids learn to ride bicycles. Caregivers must learn to monitor residents in an every changing state of health. A lap belt is a hazardous restraint for an active overweight resident. So, lose some weight.