Failure to Ensure Residents' Right to Be Free from Physical Restraints
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from the use of physical restraints unless required for medical treatment, affecting six sampled residents. In several cases, beds were placed against the wall, restricting residents' freedom of movement, without proper quarterly restraint assessments, physician orders, or care plan documentation as required by facility policy. For example, one resident with severe cognitive impairment and total dependence for activities of daily living had their bed placed against the wall for safety, but the required quarterly restraint assessment was not completed. Another resident with hemiplegia and severe cognitive impairment had their bed placed against the wall without a physician's order or care plan, and the initial restraint assessment did not recommend this intervention. Additional deficiencies included inaccurate or incomplete restraint assessments for residents with beds placed against the wall, such as a resident with hemiplegia whose restraint assessments did not reflect the use of the bed against the wall, despite a physician's order for this intervention. In another instance, a resident with dementia and muscle weakness was using a bed alarm, but there was no restraint assessment completed for this device, even though it was being used to prevent falls. Staff interviews confirmed that restraint assessments are required on admission, quarterly, and annually, but these were not consistently completed or documented. Other residents were also affected by similar lapses, including a resident with a history of falls and a physician's order for the bed against the wall, but without a corresponding quarterly restraint assessment. In some cases, staff acknowledged that placing a bed against the wall constitutes a restraint and requires a physician's order, informed consent, restraint assessment, and care plan, but these steps were not always followed. Facility policy requires that restraints be used only as a last resort, with proper documentation and regular reassessment, but these procedures were not adhered to for the residents reviewed.