Failure to Revise Care Plan for Resident Using Restraint
Penalty
Summary
The facility failed to ensure that the care plan was revised for a resident who was using a restraint. According to the facility's Restraint Evaluation and Restraint Reduction Policy, all residents using a restraint are to be evaluated and re-evaluated approximately every quarter, and care plan updates should occur quarterly or when there is a change in goals or approaches. For one resident with diagnoses including chronic obstructive pulmonary disease, history of falling, osteoporosis, and nicotine dependence, the quarterly Minimum Data Set (MDS) assessment indicated moderate cognitive impairment and the use of a chair alarm, but did not document the use of a wheelchair seatbelt. Physician's orders specified the use of a self-releasing alarming seatbelt for this resident due to unawareness of physical limitations and a diagnosis of schizoaffective disorder. However, the current plan of care only addressed the seatbelt as a fall intervention and did not address its use as a restraint. The Director of Nursing Services confirmed that there was no supporting documentation available regarding reassessment for restraints for this resident.