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F0604
D

Failure to Assess Wheelchair Seatbelt as Potential Physical Restraint

Ann Arbor, Michigan Survey Completed on 04-23-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to assess whether a seatbelt used by a resident in a motorized wheelchair constituted a physical restraint. The resident, who had diagnoses including muscle wasting, atrophy, and anoxic brain damage, was cognitively intact but dependent on staff for transfers and had limited use of only one hand. Observations and interviews confirmed that the resident was unable to independently release the seatbelt and had never been asked if he could do so. Certified Nursing Assistants and the Therapy Director confirmed the resident's inability to unlatch the seatbelt. Although the Therapy Director reported that a physical restraint evaluation had been completed, no documentation could be found until after surveyor intervention, at which point an evaluation and a physician order for the seatbelt were created.

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