Failure to Assess and Care Plan for Use of Potential Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints unless required for medical treatment, as required by policy. A resident with severe cognitive impairment, Parkinson's, Alzheimer's, and full dependence on staff for mobility and transfers was observed multiple times sitting in a recliner with the legs elevated and an over-the-bed table across their lap. The resident was unable to control the recliner or remove the table independently, and staff confirmed that the recliner's leg rest could only be adjusted manually by staff. There were no physician orders for the recliner, and the resident's medical record lacked documentation of an assessment for safety, evaluation, or consent regarding the use of the recliner and table as potential restraints. Interviews with nursing assistants, an LPN/Staff Development Coordinator, and the Director of Nursing confirmed that the resident could not operate the recliner independently and that required assessments, evaluations, and consents for the use of such equipment were not present in the medical record. The facility's policy required therapy assessment, documentation of medical symptoms warranting restraint use, consent, and care plan updates for any device that could restrict movement, none of which were completed for this resident.