Failure to Re-Evaluate Physical Restraint Use
Penalty
Summary
The facility failed to ensure ongoing re-evaluation of the need for a seatbelt used as a physical restraint for a resident with severe cognitive impairment and a history of falls. The resident, who was admitted with diagnoses including unspecified convulsions and cognitive communication deficit, was initially assessed for seatbelt use in the wheelchair on 10/11/23. Since that initial assessment, there was no evidence of a comprehensive re-evaluation of the restraint, despite facility policy requiring ongoing assessment and documentation of the need for restraints, as well as attempts at less restrictive alternatives. Observations by surveyors revealed that the seatbelt was in use during meals, contrary to a physician order to remove the self-release belt at meals. Staff interviews indicated that the seatbelt was believed to be necessary for the resident's safety due to poor balance and seizure history, and that the resident could release the belt when prompted. However, staff were unable to provide documentation of any reassessment of the restraint's appropriateness or effectiveness since the original evaluation, and the care plan had not been updated to reflect ongoing review. The resident's medical record and care plan referenced the use of the seatbelt for positioning and safety, with interventions such as releasing the seatbelt twice daily and reassessing for potential reduction. Despite these interventions, the facility could not provide evidence of ongoing comprehensive assessment or documentation as required by policy, and the restraint was not accurately reflected in the most recent MDS. This lack of ongoing evaluation and documentation led to the deficiency cited by surveyors.