Failure to Assess and Document Use of Physical Restraint
Penalty
Summary
The facility failed to assess a resident prior to the use of a physical restraint. The resident, who had diagnoses including dementia, pseudobulbar affect, anxiety, frontotemporal cognitive disorder, psychosis, major depressive disorder, and mood disorder, exhibited behaviors such as running and screaming in the hallway, physical and verbal aggression, wandering, and rejection of care. According to the physician's consult, staff would place the resident in her room and hold the door closed for approximately 30 minutes during episodes of violent behavior to prevent her from harming herself or others. A review of the resident's medical record, facility assessments, and care plan revealed no documentation of a physical restraint assessment, no physician orders for restraint use, and no care plan interventions related to restraints. The facility's policy required documentation of medical symptoms warranting restraint use, attempts at less restrictive alternatives, ongoing re-evaluation, and care plan updates, none of which were present in this case. Interviews with the Medical Director and DON confirmed the absence of incident reports, documentation, or restraint assessments for the resident.