Failure to Document and Justify Use of Physical Restraint
Penalty
Summary
A resident was observed sitting in a wheelchair near the nurse's station with a loose-fitting seat belt that the resident was unable to remove independently when prompted. The resident's records showed that the last assessment for the use of restraints or alarms was completed nearly three years prior, and this evaluation did not specify any medical condition or symptom being treated by the use of the seat belt. There was no documentation in the resident's electronic health record of ongoing re-evaluation for the need for a physical restraint, and the most recent care plan did not mention the use of a seat belt. During staff interview, it was stated that the seat belt was used to prevent falls and that care plans are typically updated after such events, but the staff member was unaware that the seat belt was not included in the current care plan. Additionally, there was no physician order for the use of the wheelchair seat belt, as required by the facility's own policy. The policy mandates a physician's order with documented rationale, appropriate nursing assessment, and care plan initiation for any restraint, as well as quarterly reassessment for restraint reduction, none of which were present in this case.