Failure to Identify and Address Wheelchair Seatbelt as a Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by policy and regulation. Specifically, a resident with moderate cognitive impairment and a history of falls was observed using a wheelchair seatbelt that was documented as 'self-releasing.' However, during an observation with the Director of Nursing Services (DNS), the resident was unable to unbuckle the seatbelt when asked, and stated he could not complete the task. The seatbelt was being used as a fall intervention, and the resident's medical record included diagnoses such as chronic obstructive pulmonary disease, osteoporosis, and schizoaffective disorder. Despite the facility's policy stating that only seatbelts which can be easily unfastened by the resident are not considered restraints, there was no documentation of restraint reduction attempts or reassessments for this resident. The lack of documentation and the resident's inability to self-release the seatbelt resulted in the facility failing to identify and address the seatbelt as a restraint, contrary to their own policy and regulatory requirements.