Failure to Ensure Resident's Freedom from Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of restraints, as evidenced by the use of hand mitts without proper assessment, physician's order, or notification to the responsible party. The resident, who was admitted with a diagnosis of Alzheimer's disease and alcoholic cirrhosis of the liver, was observed on multiple occasions wearing hand mitts while lying in bed. The facility's policy on the use of restraints requires a pre-restraining assessment, a physician's order, and consent from the resident or their representative, none of which were documented in this case. Interviews with staff revealed that the hand mitts were used due to the resident's restless behaviors, such as hitting themselves and grabbing during feeding. However, a review of the clinical records showed no assessment or physician's order for the use of the mitts, and the Director of Nursing confirmed these omissions. This lack of compliance with the facility's restraint policy resulted in the resident being restrained without the necessary evaluations and approvals, violating their right to be free from unnecessary restraints.
Plan Of Correction
1. Resident 74 discharged on 04/28/2025. 2. Facility audit was done to ensure other current residents had restraints. No other residents observed with restraints. Current and new admitted residents may be at risk for restraints. 3. DON, or designee, will educate nursing staff restraint policy, to include (1) if restraints are necessary, then the restraint assessment will be completed per guidelines and (2) a physician order will be obtained. 4. DON, or designee, will perform random audits of all new admissions to ensure no need for restraints weekly for 2 weeks, then monthly for 2 months. Results of audits will be submitted to monthly QAPI for review and recommendations.