Failure to Ensure Resident is Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by their policy. The policy, dated June 2017, mandates that restraints should only be used when medically necessary and after a thorough evaluation. However, Resident #29, who was admitted with diagnoses including Alzheimer's Disease, Repeated Falls, Dementia, and Anxiety, was observed with a self-release waist belt in her wheelchair. Despite the facility's policy, there was no assessment for a trunk restraint, and the resident's care plan included an intervention for a self-release seatbelt without proper evaluation. Observations over several days revealed that Resident #29 was unable to release the waist belt independently, indicating it functioned as a restraint. During an interview, the DON confirmed the presence of the restraint and acknowledged the need for monitoring and assessment. The DON also mentioned that the resident's daughter insisted on the use of the belt due to previous falls, but the resident's inability to release the belt contradicted the claim that it was not a restraint.