Failure to Document and Re-Evaluate Use of Physical Restraints
Penalty
Summary
A resident with diagnoses including dementia, COPD, anxiety, and psychosis was observed multiple times seated in a Broda chair with leg straps securing both legs, preventing her from getting out of the chair. These observations occurred in various locations, including the hallway and her room, both while awake and asleep. Staff were seen releasing and repositioning the leg straps at intervals. The resident's clinical record included a physician order for the use of the Broda chair with straps for safety and positioning, with instructions for release and repositioning every two hours and quarterly review for continued use. However, documentation in the resident's record was incomplete. The Minimum Data Set (MDS) assessment did not document daily use of limb restraints, and the care plan referenced the use of the Broda chair with straps but lacked specific details. The informed consent form for restraint use did not specify the recommended duration or release schedule. Additionally, the quarterly adaptive device review noted the device's initiation and rationale but lacked evidence of previous quarterly reviews. The Director of Nursing Services confirmed that no further evaluations had been completed, despite facility policy requiring ongoing re-evaluation of restraint need.