Failure to Assess and Obtain Order for Use of Physical Restraint
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including Alzheimer's disease, dementia, and severely impaired cognition, was found to be using gardening gloves with Velcro fasteners on both hands to prevent her from chewing on her fingers. The gloves were applied in such a way that the resident's hands were balled up inside the gloves, restricting movement, and the Velcro around the wrists prevented her from removing them independently. The medical record did not contain a physician's order for the gloves to be used as a restraint, nor was there documentation of a restraint assessment being completed for this intervention. Staff interviews confirmed that the gloves were used because the resident would chew on her fingers and that other interventions, such as skin preparation and bandages, had been attempted without success. The DON acknowledged that the physician was aware of the situation but verified that no order or restraint assessment was in place for the use of the gloves as a restraint. Facility policy required a restraint assessment and physician order prior to the use of any restraint, which was not followed in this case.