Failure to Ensure Residents' Right to Be Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless required for medical treatment, as evidenced by multiple instances involving five residents. For one resident with a history of falls and severe cognitive impairment, the facility did not accurately complete the physical restraint assessment form to reflect the use of a bed pad alarm, despite having a physician's order and care plan for fall risk. The restraint assessment did not indicate the current type of restraint or the reason for its use, and the admissions nurse did not document whether less restrictive measures had been attempted prior to the application of the restraint. Another resident with dementia and a history of falls was found to be using a bolstered mattress without a current physician's order, informed consent, restraint assessment, or care plan after discharge from hospice care. The facility continued to use the bolstered mattress as a restraint without completing the necessary documentation or obtaining consent from the resident's representative. Staff interviews confirmed that the required assessments and documentation were only completed after the deficiency was identified. Additional deficiencies were observed for three other residents. Two residents had their beds placed against the wall, which staff acknowledged as a form of restraint that limited the residents' ability to exit the bed from one side. There were no physician's orders, informed consents, restraint assessments, or care plans for this intervention. Another resident had three side rails up and a side table blocking the open side of the bed, also without the required physician's order, informed consent, restraint assessment, or care plan. In all cases, staff interviews confirmed that these interventions were implemented without following the facility's policy and procedure for restraint use, which requires pre-restraining assessment, physician's order, informed consent, and care planning.