Failure to Obtain Informed Consent for Use of Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraint by not completing informed consent for the use of bed siderails and a geri-chair with lap tray, as required by individualized assessment. The resident in question had diagnoses including encephalopathy, COPD, and unspecified dementia, with severely impaired cognitive skills and required moderate assistance for activities of daily living. Despite these conditions, there was no physician order for the use of bed siderails, and the care plan did not address their use. Additionally, the medical record lacked informed consent documentation for both the bed siderails and the geri-chair with lap tray. Observations over several days showed the resident sitting in a geri-chair with a lap tray in the hallway, sometimes unattended, and later lying in bed with bed siderails up. Staff interviews confirmed that there should have been orders and care plans for these devices, and that informed consent was necessary due to the potential for these devices to restrict movement. The physical restraint assessment recommended the use of a geri-chair with tray due to poor safety judgment, but documentation was incomplete and did not reflect proper assessment or consent procedures. Facility policy required that any device restricting a resident's movement, such as bedrails or a geri-chair with a tray, be considered a restraint if the resident could not remove it independently. The policy also mandated a physician's order and informed consent for such devices, specifying the reason, benefit, type, and duration of restraint. In this case, these requirements were not met, resulting in a violation of the resident's right to be treated with respect and dignity regarding the use of physical restraints.