Resident Restraint Violation
Penalty
Summary
The facility failed to protect a resident's right to be free from physical restraint. The incident involved a resident who was re-admitted to the facility with a diagnosis that included aphasia, affecting their ability to speak. The resident's cognitive assessment indicated severe impairment. During an incident, the resident was found in their room, in a wheelchair, with a gait belt around their abdomen secured to the wheelchair. The Certified Occupational Therapy Assistant (COTA) discovered this situation and reported it to the Administrator. The resident was assessed and found to have no injuries. The investigation revealed that the resident had been assigned a sitter for one-to-one supervision. The sitter reported that the resident kept getting up, and she used the gait belt to keep the resident in the wheelchair until another staff member returned. The sitter claimed she did not attach the gait belt to the wheelchair, but the COTA observed it secured to the chair. Interviews with staff indicated that the use of the gait belt was not in line with the facility's training on restraint and neglect. The staff involved were educated on the proper procedures following the incident.
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. Tag 0024 - Right to Be Free from, etc. 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 [date]. Round sheets will be turned into the Administrator daily Monday-Friday indicating if anything is observed that needs to be evaluated as a possible violation 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 violation. If found, proper notifications to be completed if possible. 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.