Failure to Assess and Document Use of Physical Restraint-Related Devices
Penalty
Summary
The facility failed to comprehensively assess and document the use of physical restraint-related devices for four residents, including bed rails/mobility bars, beds placed against the wall, and a wander guard. For one resident with moderate cognitive impairment and a history of psychosis, a wander guard was ordered and used daily, but there was no documented safety evaluation or care plan addressing its use. Staff interviews confirmed that required assessments and documentation were missing. Another resident, who was cognitively intact, had a physician's order for their bed to be placed against the wall as a safety device. However, there was no evidence of a Physical Therapy evaluation or documentation of less restrictive alternatives being attempted prior to this intervention. The Director of Nursing acknowledged that such documentation and evaluation should have been completed before implementing the intervention. For a resident with severe cognitive impairment, mobility bars were ordered for safe mobility, but both bars were found to be loose and unstable during inspection. Staff confirmed that the bars should have been solid and stationary, and recognized the risk of injury or entrapment. There was no documentation of a comprehensive assessment for the use of these mobility bars, nor evidence that less restrictive alternatives were considered. Similarly, another resident with severe cognitive impairment had their bed placed against the wall without an order, assessment, or care plan, and no documentation of less restrictive alternatives. Staff interviews revealed confusion about responsibility for assessments and a lack of required documentation in the electronic health record.