Failure to Assess and Document Potential Physical Restraints
Penalty
Summary
The facility failed to ensure that potential physical restraints, specifically beds positioned against the wall and the use of mobility bars, were properly assessed, care planned, and documented for three residents. For one resident who was cognitively intact and dependent on staff for toileting and dressing, the bed was observed against the wall without a physical restraint evaluation or care plan in place. Staff confirmed that there was no assessment or care plan for this setup, and acknowledged that these should have been completed. Another resident with a right femur fracture and moderate cognitive impairment was observed with both their bed against the wall and a mobility bar attached, but there was no documentation of a restraint evaluation for either device. Staff interviews confirmed that assessments and orders were missing for these arrangements. A third resident, who had dementia, depression, anxiety, and muscle weakness, also had their bed against the wall without a completed restraint assessment or care plan. Staff interviews consistently indicated that restraint assessments and consents were expected but not completed for these residents.