Failure to Assess and Document Use of Physical Restraint Device
Penalty
Summary
The facility failed to complete required assessments before or during the use of a specialized chest harness, which functioned as a physical restraint for a resident with significant mobility and neurological impairments. Facility policy stated that physical restraints would only be used as a last resort, with physician orders, consent, and after less restrictive measures had been tried and failed. The policy also required qualified staff to evaluate residents for device needs and to regularly check devices for safety and skin integrity. However, there was no evidence of an assessment, consent, or regular monitoring related to the harness used for this resident. The resident in question had a complex medical history, including Spastic Diplegic Cerebral Palsy, Epilepsy, Conversion Disorder with Seizures, Scoliosis, Postural Kyphosis, and reduced mobility. The resident's care plan acknowledged the use of a safety harness in the wheelchair and directed staff to assess circulation every shift, but there was no documentation of these checks on the Treatment Administration Record (TAR) or Medication Administration Record (MAR) for the relevant periods. The resident was observed to be dependent for dressing and had poor memory, and the harness was justified in a seating and mobility evaluation as necessary for safety due to involuntary muscle spasms and decreased postural control. During interviews, staff members, including the MDS Coordinator and DON, were unable to provide documentation of assessments, skin checks, or signed consent for the harness. The harness was not listed on the TAR or MAR, and staff were unclear about whether it constituted a restraint or if appropriate monitoring was being conducted. The lack of assessment, documentation, and consent for the use of the harness constituted a failure to comply with facility policy and regulatory requirements regarding physical restraints.