NORTH HOLLYWOOD, CA - Federal inspectors cited Sherman Village Health Center for multiple violations during a September 2024 inspection, including the unauthorized use of physical restraints and failures to properly screen residents for mental health conditions that could qualify them for additional services.
Improper Use of Physical Restraints Without Medical Orders
The most significant violation involved a resident with epilepsy who was subjected to unauthorized physical restraints. Inspectors found that Resident 37, who had been diagnosed with epilepsy and lacked capacity to make decisions, was being restrained using pillows placed underneath his mattress and bed rails without proper medical authorization.
During multiple observations between September 3-6, 2024, inspectors documented that the resident's bed was positioned against the wall with pillows deliberately placed under the right side of the mattress to create an angled incline. Staff members confirmed this setup was intended to prevent the resident from attempting to leave his bed.
A Restorative Nurse Aide told inspectors that "Resident 37 is very active and makes attempts to jump out of the bed" and explained that both staff and family members had been placing pillows under the mattress. The resident's family member stated she preferred this arrangement because "the resident jumps out of the bed."
The facility's Minimum Data Set Coordinator acknowledged during the inspection that the pillows should not be placed under the mattress because "it can be considered a restraint." More critically, when reviewing the resident's medical orders, the coordinator confirmed that there were no physician orders authorizing either the pillow placement or the bed rails being used.
Medical Assessment Documentation Failures
The restraint issue was compounded by inaccurate documentation in the resident's Minimum Data Set assessment. Despite using bed rails and mattress modifications since before May 2024, the MDS incorrectly indicated that the resident did not use bed rails or other types of restraints. This misrepresentation meant the facility was not properly monitoring or planning care for a resident who was actually being physically restricted.
Federal regulations require that any device used to restrict a resident's movement must be ordered by a physician and properly documented. Bed rails and positioning devices can only be considered assistive equipment rather than restraints when they are medically necessary and properly authorized. Without such orders, these interventions constitute unauthorized physical restraints.
The medical significance of this violation is particularly concerning given the resident's epilepsy diagnosis. Individuals with seizure disorders require carefully planned safety interventions that consider the risks of injury during seizures while maintaining their freedom of movement when possible. Unauthorized restraints can create additional safety hazards and may violate the resident's rights.
Mental Health Screening System Breakdown
The facility also failed to properly coordinate mental health screening requirements for residents who needed additional psychiatric services. Two residents with documented mood disorders were not referred for required Level II mental health evaluations despite having diagnoses that should have triggered more comprehensive screening.
The Preadmission Screening and Resident Review (PASARR) system is designed to ensure that nursing home residents with serious mental disorders receive appropriate specialized services. When a resident's initial Level I screening is negative but they are later found to have mental health conditions, facilities must request updated evaluations to determine what additional services might be needed.
Resident 42 was admitted with diagnoses including "unspecified mood disorder," anxiety, and depression, yet his initial PASARR screening indicated no serious mental disorder. Similarly, Resident 52 was readmitted with a mood disorder diagnosis after having a negative initial screening. In both cases, facility staff acknowledged the screening inaccuracies but failed to request the required Level II evaluations.
The facility's Minimum Data Set Coordinator told inspectors that these oversights meant "the potential negative affect would be that the resident was not provided the proper mental health care." The Director of Nursing confirmed that both residents "had mental health issues and would benefit from any additional mental health services."
Impact on Quality of Care
These screening failures can have significant consequences for residents' wellbeing. Level II PASARR evaluations determine whether residents need specialized mental health services beyond what nursing facilities typically provide. This might include access to qualified mental health professionals, specialized programming, or additional therapeutic interventions.
Mental health conditions in nursing home residents require coordinated care approaches that address both psychiatric symptoms and their interaction with other medical conditions. When facilities fail to identify residents who qualify for enhanced mental health services, those individuals may not receive optimal treatment for conditions that significantly impact their quality of life.
The restraint violations present immediate safety concerns. Physical restraints, even when well-intentioned, can lead to serious injuries including falls, circulation problems, and psychological distress. Federal regulations recognize that restraints should be a last resort, used only when medically necessary and with proper safeguards in place.
Regulatory Requirements and Best Practices
Federal nursing home regulations require comprehensive care planning that addresses all aspects of a resident's condition. For residents needing positioning or safety interventions, facilities must develop individualized approaches that maximize independence while ensuring safety. This includes obtaining proper physician orders, documenting interventions in care plans, and regular reassessment of continued need.
The PASARR screening process serves as a critical safety net to ensure residents with mental health conditions receive appropriate services. Facilities must maintain systems to verify screening accuracy and update evaluations when residents' conditions change. This requires coordination between admissions staff, nursing personnel, and clinical coordinators.
Industry best practices emphasize person-centered care planning that involves residents and families in developing safety strategies. For residents with cognitive impairments or seizure disorders, this might include environmental modifications, increased monitoring, or assistive devices - but always with proper medical authorization and documentation.
Additional Issues Identified
The inspection also revealed problems with care plan development and implementation. Resident 37 lacked a care plan addressing the positioning interventions being used, while another resident did not have appropriate care planning for enhanced infection control precautions. These documentation gaps can lead to inconsistent care delivery and missed opportunities to address residents' changing needs.
The facility's own policies required comprehensive assessment and care planning that allows residents to reach their highest level of functioning. The violations suggest systemic issues with implementing these policies consistently across different departments and shifts.
Federal regulators classified these violations as having "minimal harm or potential for actual harm" but affecting multiple residents. The facility must submit a plan of correction addressing how they will prevent similar violations in the future, including staff training, policy updates, and monitoring procedures to ensure compliance with federal regulations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sherman Village Hcc from 2024-09-06 including all violations, facility responses, and corrective action plans.
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