Failure to Evaluate and Obtain Consent for Restraint Use
Penalty
Summary
Fox Subacute at South Philadelphia was found to be non-compliant with federal and state regulations regarding the use of physical restraints. The facility failed to evaluate the need for restraints and did not assess the least restrictive measures for a resident who was using hand mitts as restraints. The resident, admitted with chronic respiratory failure and a tracheostomy, had a physician's order for hand mitts to be removed every two hours for skin integrity checks. However, there was no documented evidence of an evaluation of the necessity of these restraints or consideration of less restrictive alternatives. Additionally, the facility did not obtain informed consent prior to the use of restraints on the resident. The clinical records lacked documentation of informed consent, and the restraint consent provided during the survey was undated, offering no indication of when consent was obtained. The Director of Nursing confirmed these deficiencies, acknowledging the absence of evaluation and documented informed consent for the use of restraints on the resident.
Plan Of Correction
1. Resident R5 had a Restraint Assessment completed by the nurse. 2. Other Residents with Restraints were found to have complete Restraint documentation. 3. In-servicing was given to nurses regarding the Policy of obtaining consents and completing a Restraint assessment prior to applying the Restraint. 4. Random audits will be conducted weekly by ADON or designee to check for all components of Restraint application. Results of audits will be brought to the monthly QAPI meeting, x3 months, overseen by the Administrator.