Failure to Assess, Care Plan, and Re-Evaluate Use of Physical Restraint
Penalty
Summary
The facility failed to ensure the use of the least restrictive alternative and did not provide adequate assessment, care planning, or ongoing re-evaluation for the use of a seatbelt restraint for a resident with Lennox-Gastaut Syndrome, wheelchair dependence, aphasia, and gastrostomy status. The resident was observed on multiple occasions wearing a seatbelt restraint while in her wheelchair, and staff interviews confirmed that the restraint was used every time the resident was in the wheelchair. The care plan referenced the use of the seatbelt for safety due to falls and seizures, but did not include interventions to address risks related to restraint use, monitoring or supervision requirements, or parameters for release of the restraint. Record review revealed that there was no active physician's order specifying the application, monitoring, or removal of the seatbelt restraint. The medication and treatment administration records included tasks for staff to document the resident wearing the seatbelt, but did not provide additional monitoring directives. There was also no evidence of a specific assessment related to restraint use in the electronic medical record, and the consent form for restraint use was incomplete, lacking details about the type of restraint. Interviews with staff indicated that less restrictive alternatives were not attempted prior to the use of the restraint, and that the restraint was only removed at the end of the day when the resident went to bed. The facility's policy requires behavioral interventions to be exhausted before restraint use, documentation of less restrictive alternatives, ongoing re-evaluation, and care planning to address risks, but these steps were not followed. The facility relied on the request of the resident's mother for continued restraint use without proper documentation or assessment as required by policy.