| 6400.72(a) | On 9/24/25 at 1:30PM there were no screens in any of the windows of the home. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | The Director of Maintenance has purchased and put in place tension-fit window screens for every window in the home that has the ability to open. These screens fit securely in the window frames, and are readily available for use should the residents of the home wish to open a window. |
10/03/2025
| Implemented |
| 6400.207(5)(II) | On 9/24/2025 at 1:30PM, Individual #1's bed was observed with padded bilateral upper bedrails that had the potential to restrict the movement or function of Individual #1's body. Individual #1's current order by the Primary Care Physician was on the physical examination dated 8/21/25, where it indicated "Side rails for safety" in the Physical Limitation section. Staff interviews reveal that Individual #1 is unable to easily remove the device or indication or request the immediate removal by a staff person. The agency has not made a determination that the bedrails are not a mechanical restraint or medically needed to include but not limited to the completion of the "mechanical restraint decision tree" and the attempted use of alternative devices.
On 9/24/2025 at 1:32PM, Individual #2's bed was observed with bilateral upper bedrails that had the potential to restrict the movement or function of Individual #2's body. Individual #2's current order, dated 7/24/25, indicated "siderails for safety" was completed by the agency's Certified Registered Nurse Practitioner. Staff interviews reveal that Individual #2 is unable to easily remove the device or indication or request the immediate removal by a staff person. The agency has not made a determination that the bedrails are not a mechanical restraint or medically needed to include but not limited to the completion of the "mechanical restraint decision tree" and the attempted use of alternative devices.
On 9/24/2025 at 1:31PM, Individual #3's bed was observed with bilateral upper bedrails that had the potential to restrict the movement or function of Individual #3's body. Individual #3's current order, dated 6/19/25, indicated "client to utilize siderails while in bed for client safety" was completed by the agency's Certified Registered Nurse Practitioner. Staff interviews reveal that Individual #3 is unable to easily remove the device or indication or request the immediate removal by a staff person. The agency has not made a determination that the bedrails are not a mechanical restraint or medically needed to include but not limited to the completion of the "mechanical restraint decision tree" and the attempted use of alternative devices. | A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Balance or support to achieve functional body position, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement. | For individuals #1, #2, and #3 identified in the deficiency, the POC must outline specific, immediate corrective actions.
Individual Functional and Risk-Benefit Assessment
The agency will conduct a new, comprehensive assessment for individual #1, #2, and #3 - with input from their physician and parent and/or guardian. This assessment will specifically identify the medical symptom or functional need (e.g., mobility assistance, repositioning) that the bed rails address. The assessment will be documented on the agency's standardized form and reviewed by nursing for completeness and accuracy.
Medical Order Review
A licensed nurse will verify that a valid, current physician's order is in place for individual #1, #2, and #3 - using bed rails. The order will specify both the type of rail and the medical symptom or diagnosis for which the bed rail is prescribed. This order will be kept on file in the residents' records and renewed annually, or sooner if there is a change in the individual's condition.
ISP and HRST Update
The residents' Individual Support Plan (ISP) will be updated to include the identified need for the use of bed rails, ensuring that the intervention is integrated into the person's overall plan of care and treatment supports. The resident's Health Risk Screening Tool (HRST) will also be updated to reflect the use of bed rails and the diagnosis or medical condition that necessitates their use.
The assigned Program Specialist will ensure that updates are submitted to the Supports Coordinator, and nursing will verify HRST accuracy.
Entrapment Mitigation
Any bed rails in use will be inspected to ensure they meet manufacturer specifications and entrapment prevention standards consistent with FDA Hospital Bed Safety Workgroup (HBSW) guidelines.
Informed Consent
Informed consent for the use of bed rails will be reviewed and reaffirmed with the resident or their parent and/or guardian, confirming understanding of both the risks and benefits. Consent will be re-reviewed annually or with any change in the individual's condition.
Documentation Review
The care plan will be updated to clearly identify the medical indication for the bed rail and detail how its use assists the resident's condition. The care plan will be reviewed and updated as needed and at least annually, in conjunction with the functional and risk-benefit assessment. |
12/01/2025
| Implemented |