Failure to Assess and Monitor Use of Restraints and Alarms
Penalty
Summary
The facility failed to routinely assess the necessity, appropriateness, and least restrictive use of seat belts and alarms for residents, as required by policy. For one resident with hemiplegia, hemiparesis, and moderate cognitive impairment, a Velcro seat belt was ordered and applied for positioning and safety, but there was no assessment at the time of application or thereafter to determine if the device was necessary, appropriate, or the least restrictive option. The care plan referenced the seat belt as a fall intervention but did not include any plan for monitoring or reassessment, and there was no documentation justifying its use or monitoring its continued need. Staff confirmed the seat belt was used to prevent unassisted rising, and the resident was able to self-release the belt with the unaffected hand, but this was not routinely assessed or documented. Another resident with multiple diagnoses, including dementia and moderate cognitive impairment, had both an alarming Velcro seat belt and a pressure alarm ordered for safety. There were no assessments completed upon application of these devices or subsequently to determine their necessity or appropriateness. The care plan addressed the pressure alarm but not the seat belt, and neither device was monitored or reassessed for continued need or least restrictiveness. Documentation did not justify the use of these devices, and there was no record of their removal, despite staff indicating the devices were no longer in use. Facility policy required a pre-restraining assessment and ongoing re-evaluation for any restrictive device, as well as documentation of the resident's response to interventions. The facility identified 13 residents with seat belts or alarms as restrictive devices, but failed to ensure assessments and documentation were completed as required. Observations and interviews confirmed that devices were used or removed without proper assessment, monitoring, or documentation, resulting in a deficiency related to the use of physical restraints and restrictive devices.
Plan Of Correction
Resident #3 and #25 were immediately assessed and found to have no adverse effects. All residents who utilize alarms or seatbelts have the ability to be affected. Seatbelt order for resident #25 was DCed immediately by DON on 5/21/25. Alarm for resident #3 was requested to stay in place by resident. Chart was reviewed by DON immediately on 5/21/25 to ensure proper documentation was in place. All residents with alarms/restrictive devices were reviewed by IDT on 5/28/25 to ensure the least restrictive device was in place and that remaining devices were appropriate. Education on appropriate alarm and restrictive device usage and ongoing assessment was provided by DON to all staff on 5/22/25. DON/designee to review 3 residents with an alarm or restrictive device in place weekly for 4 weeks to ensure they are necessary, being routinely reviewed, and least restrictive. Results of audit to be reviewed in QAPI.