Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
A resident with diagnoses including Alzheimer's disease, anxiety disorder, major depressive disorder, and edema was subjected to the use of a geri-chair with a lap tray, which functioned as a physical restraint. The resident had previously been hospitalized and returned to the facility with decreased trunk control, leading to the initial use of the geri-chair for support. However, subsequent assessments and staff interviews indicated that the resident had regained strength and could sit unsupported, yet the use of the geri-chair and lap tray continued. Observations and interviews revealed that the lap tray and positioning of the geri-chair restricted the resident's mobility, preventing her from standing or moving independently. Multiple staff members, including CNAs and the DON, acknowledged that the resident was unable to remove the tray herself and frequently expressed distress, agitation, and frustration while restrained. Documentation in nursing progress notes and behavior logs showed repeated episodes of the resident banging on the tray, yelling, and attempting to get out of the chair, indicating ongoing emotional and physical discomfort. Despite the resident's improved physical condition and clear behavioral signs of distress, the facility continued to use the geri-chair and lap tray, primarily to reduce falls and for staff convenience, rather than for a current medical necessity. The facility's own restraint policy prohibits the use of physical restraints for convenience and requires reassessment with any significant change in condition. The required reassessment and communication with the hospice care coordinator regarding the resident's improved status and negative response to the restraint did not occur, resulting in the continued inappropriate use of a physical restraint.