Failure to Document Restraint Use in Resident Care Plan
Penalty
Summary
The facility failed to develop and document a comprehensive, person-centered care plan addressing the use of a seat belt restraint for a resident with a history of rhabdomyolysis and muscle spasms. The resident, who was cognitively intact and able to independently buckle and unbuckle the seat belt, had requested the use of the seat belt for safety due to muscle spasms that previously caused falls from the wheelchair. The seat belt was ordered per the resident's request and was to be checked every shift for the resident's ability to unbuckle if needed. Despite these interventions being in place and documented in the Medication Administration Record and Restraint Evaluation, the resident's care plan did not include any reference to the seat belt as an intervention to prevent falls. Interviews confirmed that the care plan lacked this information, and the MDS coordinator acknowledged that restraints should be care planned so staff are aware of necessary care and monitoring requirements.