Failure to Ensure Resident Free from Physical Restraints
Penalty
Summary
A resident with diagnoses including hypertension, psychotic disturbance, schizophrenia, and gastro-esophageal reflux disease was found lying in bed with all four side rails up. The physician order sheet did not document an active order for a restraint, but did include an order for half side rails to be used for mobility and repositioning. The resident's Minimum Data Set indicated cognitive impairment with a BIMS score of 6 out of 15, and documented daily use of side rails as physical restraints. The care plan did not initially address a restraint problem, and was only updated to include half side rails after the incident. Staff interviews revealed that all four side rails were up, contrary to the physician's order for only half side rails. Nursing staff were either unaware of the reason for all four side rails being up or acknowledged that only half side rails should have been used. Facility policy defines physical restraints as any device that restricts freedom of movement and requires specific physician orders detailing type, reason, duration, and justification. The use of all four side rails without proper order or documentation resulted in the resident being confined to bed, constituting a failure to ensure the resident was free from physical restraints.