MODESTO, CA - Federal inspectors cited Windsor Post-acute Healthcare Center of Modesto for multiple violations including the unauthorized use of restraints on a stroke patient receiving hospice care.
Unauthorized Restraint Use on Vulnerable Resident
During an August 2024 federal inspection, surveyors discovered that facility staff had applied a sock and bandage combination to the left hand of a stroke patient without proper authorization. The resident, who had suffered a stroke in February 2024 and was receiving hospice care, was found with the restraining device during multiple observations by inspectors.
A restorative nursing assistant observed on July 30, 2024, was unable to explain why the sock and bandage combination had been placed on the resident's hand. When questioned by inspectors, staff members provided conflicting information about the unauthorized restraint.
According to the inspection report, the resident's care plan included application of a sock to the hand but failed to identify it as restraint use, which violates federal regulations requiring proper documentation and authorization for any restraining devices.
Staff Awareness Issues and Lack of Physician Orders
Multiple staff members interviewed during the inspection demonstrated concerning gaps in knowledge about the restraint use:
- The Licensed Vocational Nurse responsible for wound care stated she was unaware of the sock application and confirmed the resident should not have been wearing one - The day shift nurse reported being notified about the sock at 6:30 AM on July 30 but became distracted and forgot to investigate further - A hospice nurse who visited the facility stated she had never seen the sock and that hospice had not ordered such an intervention
The facility's Assistant Director of Nursing acknowledged that any device preventing a resident from accessing their body required a physician's order, which was not obtained in this case.
Regulatory Violations and Policy Requirements
The facility's own restraint policy, dated April 2017, clearly states that restraints may only be used to treat medical symptoms and never for discipline, staff convenience, or fall prevention. The policy defines restraints based on the resident's functional status, noting that if a resident cannot remove a device in the same manner staff applied it, the device constitutes a restraint.
Hand mitts are specifically listed as examples of devices that may be considered physical restraints under the facility's policy. The unauthorized use of the sock and bandage combination violated multiple aspects of this policy framework.
Additional Regulatory Deficiencies Found
Beyond the restraint violations, inspectors identified several other concerning deficiencies:
Mental Health Assessment Failures: The facility failed to complete required Level II mental health evaluations for a resident with schizoaffective and bipolar disorders. Despite receiving notice that a comprehensive evaluation was needed, staff did not follow through with the required assessment process.
Inadequate Care Planning: Baseline care plans failed to include critical information such as side rail usage for mobility assistance and code status documentation for hospice patients. These omissions prevented staff from having complete information needed to provide appropriate care.
Delayed Constipation Treatment: One resident experienced constipation for ten days before receiving appropriate intervention. The facility's bowel protocol called for treatment after three days, but staff waited five days to initiate the prescribed regimen, requiring eventual emergency room evaluation.
Hydration and Nutrition Management Issues
Inspectors found significant problems with fluid management for a COVID-19 patient who required two separate intravenous fluid treatments within ten days of admission. The facility's registered dietitian failed to complete a timely nutrition assessment, waiting 14 days after admission to calculate the resident's fluid needs at 2,400 milliliters per day.
Despite this assessment, the care plan set an inadequate goal of only 1,000 milliliters of fluid intake per day. The facility also failed to monitor supplement intake, making it impossible to determine whether the resident received ordered nutritional support.
Systemic Quality Assurance Problems
The inspection revealed fundamental failures in the facility's quality oversight systems. Inspectors found that Windsor Post-acute Healthcare lacked a comprehensive Quality Assurance Performance Improvement (QAPI) plan, despite federal requirements for such programs.
The facility also failed to conduct required facility-wide assessments to determine necessary resources for resident care. The administrator admitted that annual facility assessments for 2020, 2021, 2022, and 2023 were not available, and the current assessment had been hastily created only after inspectors arrived.
Medical Standards and Best Practices
Proper restraint use in nursing facilities requires strict adherence to federal regulations designed to protect vulnerable residents. Any device that restricts movement or access must be ordered by a physician, documented in care plans, and regularly assessed for continued necessity.
The unauthorized restraint use at Windsor Post-acute Healthcare violated these fundamental protections. Stroke patients, particularly those receiving hospice care, require careful monitoring of their comfort and dignity rather than restrictive interventions without medical justification.
Facilities must maintain comprehensive policies and training programs to ensure staff understand when restraints are appropriate and how to implement them safely. The confusion and lack of awareness demonstrated by multiple staff members suggests systemic gaps in education and oversight.
Regulatory Response and Accountability
The Centers for Medicare & Medicaid Services classified most violations as causing "minimal harm or potential for actual harm," though the systemic nature of the problems affected many residents. The facility assessment and quality assurance deficiencies were noted as having potential impact on all 161 residents in the facility.
Federal regulations require nursing facilities to maintain detailed documentation of all care decisions and to ensure staff receive appropriate training on resident rights and safety protocols. The multiple documentation failures and policy violations found during this inspection demonstrate the need for comprehensive corrective action.
The inspection findings highlight the importance of robust oversight systems in nursing facilities, particularly for vulnerable populations such as stroke patients receiving end-of-life care. Proper training, clear policies, and consistent implementation of safety protocols are essential to prevent unauthorized restraint use and ensure residents receive appropriate, dignified care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Windsor Post-acute Healthcare Center of Modesto from 2024-08-02 including all violations, facility responses, and corrective action plans.
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