Resident Restrained with Gait Belt in Wheelchair
Penalty
Summary
The facility failed to protect a resident's right to be free from physical restraints. The incident involved a resident who was re-admitted to the facility with severe cognitive impairment and other medical conditions. During an incident, the resident was found in his wheelchair with a gait belt around his abdomen, secured to the wheelchair. The Certified Occupational Therapy Assistant (COTA) discovered this when she went to retrieve the resident for therapy. The investigation revealed that the resident's sitter, who was assigned to provide one-on-one supervision, used the gait belt to prevent the resident from getting up, as he was attempting to do so repeatedly. The sitter claimed she was holding the gait belt and did not attach it to the wheelchair, but the COTA found it secured. Interviews with staff members, including the Social Services Director and Assistant Staff, confirmed the use of the gait belt as a restraint. The Social Services Director mentioned that all staff had been educated on abuse and neglect training, and he had never witnessed a staff member restrain a resident. The Assistant Staff reported the incident to her supervisor immediately upon noticing the restraint. The sitter involved in the incident stated she had never seen the gait belt in the room before and was holding it to prevent the resident from falling. She was sent home during the investigation and later received training on abuse and neglect, emphasizing not to use gait belts as restraints. The facility concluded that the sitter used the gait belt to keep the resident from getting up until the COTA returned, which constituted a failure to protect the resident's rights.
Plan Of Correction
Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted solely because of requirements under state and federal laws. F 604- Right to Be Free from Physical The gait belt was immediately removed from the resident and chair by the certified assistant (COTA). The COTA immediately notified her supervisor, the director of rehabilitation (DOR), who immediately reported to the facility Administrator. The Administrator immediately spoke to the staff member and relieved her of duty until further investigation is completed. Resident was assessed and found to have no injuries nor affected by this use of the gait belt. - 100% audit of all residents in the facility to assess if gait belts were being utilized anywhere else with no observations of use were observed. - Ten residents were interviewed by Social Services to determine if the staff treated them with dignity and respect and if they had ever been in a situation that made them feel uncomfortable, do they feel safe? 100% of the interviewees had no negative responses. - Ten staff members were interviewed to see if they had ever observed a staff member, family member, or another resident restrain a resident. 100% of the responses received no indication that it had ever been observed. 100% Staff education completed by on Neglect and Misappropriation and post-test administered to ensure comprehension or received education that gait belts cannot be used as a form of restraint. As part of a systematic change, Nursing Home Administrator/Designee while on rounds will observe for the use of gait belts. Education was provided to Department Heads on the addition of observation for the use of gait belts and completed on round sheets. Round sheets will be turned into the Administrator daily Monday-Friday indicating if anything is observed that needs to be evaluated as a possible restraint so that immediate action can be taken. Weekend Supervisor will complete facility rounds observing each room looking for any item that could be identified as a restraint. If found, proper notifications to be completed if possible are observed. The rounds will be completed daily for a period of 4 weeks, then twice for one month, and then weekly for one month until substantial compliance is met. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.