Failure to Prevent Use of Physical Restraint Without Assessment or Physician Order
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by policy and regulation. Facility policy states that physical restraints may only be used to treat medical symptoms and must never be used for staff convenience or discipline. For one resident with severe cognitive impairment, functional limitations in range of motion, and a high risk for falls, observations revealed that the resident's bed was pushed against the wall and a wedge was positioned under the sheets on one side. The use of the bed against the wall was confirmed by a registered nurse, who acknowledged that this could act as a restraint. A review of the resident's clinical record showed no documentation of a physical restraint assessment or a physician's order authorizing the bed to be pushed against the wall. The resident's care plan identified a high risk for falls but did not include the use of the bed against the wall as an intervention. The deficiency was identified through review of facility policy, clinical records, direct observation, and staff interview.