Failure to Properly Assess and Document Seatbelt Use
Penalty
Summary
The facility failed to ensure proper documentation and assessment for the use of a seatbelt device on a resident, identified as R7, who was observed in a wheelchair with the seatbelt clasped. R7, who has severe cognitive impairment and a history of falls, was unable to independently release the seatbelt without cues and assistance. The facility did not have a physician's order, consent, or a current assessment for the seatbelt device, which was last assessed in 2021. The care plan inaccurately listed the seatbelt under 'falls' for safety, despite no indicators for restraint use being noted in the resident's assessments. The Director of Nursing (DON) claimed the facility was restraint-free and stated that the seatbelt was not considered a restraint because R7 could remove it with assistance. However, the seatbelt was not reassessed quarterly as required, and there was a discrepancy between the care plan and the family's understanding of the seatbelt's purpose. The family believed the seatbelt was for comfort due to R7's past work experience, while the facility's documentation suggested it was for trunk support and positioning. The lack of proper assessment and documentation led to the deficiency noted by the surveyors.