Failure to Follow Restraint Policy and Monitoring Procedures
Penalty
Summary
The facility failed to follow its policy and procedure regarding the use of physical restraints for one resident by not ensuring that the physician's order for Peek-A-Boo mittens included a specific reason for their use that would benefit the resident's medical symptom. The physician order and documentation indicated the use of mittens and instructions for their release and skin checks, but did not specify the medical symptom necessitating the restraint as required by facility policy. The facility's policy states that restraint orders must include the specific reason for use and how it benefits the resident's medical condition. Additionally, the facility did not consistently monitor and assess the resident's tolerance when the Peek-A-Boo mittens were removed. Observations showed that the resident was left without mittens and without staff present in the room on multiple occasions. Interviews with staff confirmed that mittens were sometimes removed without direct supervision, and that the resident was at risk of pulling out medical devices such as a tracheostomy and gastrostomy tube during these periods. Staff also provided inconsistent information regarding the frequency and process for removing the mittens, and acknowledged that proper assessment and monitoring were not always performed during restraint release. The resident involved had a history of tracheostomy, Tourette's disorder, gastrostomy, and acute respiratory failure, and was dependent on staff for all activities of daily living. The Minimum Data Set indicated moderately impaired cognitive skills and no documented use of restraints, despite the ongoing use of mittens. The facility's failure to ensure proper physician orders and monitoring during restraint use did not align with its own policy and placed the resident at risk during periods when the mittens were removed.