Failure to Ensure Residents Are Free from Physical Restraints Without Proper Assessment and Documentation
Penalty
Summary
The facility failed to ensure that two residents were free from the use of physical restraints unless required for medical treatment. For one resident with severe cognitive impairment and multiple diagnoses, including encephalopathy, COPD, and dementia, there was no physician's order for the use of bed siderails, and no informed consent was obtained for the use of bed siderails or a geri-chair with a lap tray. The care plan did not address the use of bed siderails, and the physical restraint assessment was not properly documented. Observations showed the resident was repeatedly placed in a geri-chair with a lap tray and left unsupervised, and was also found in bed with siderails up, without the necessary documentation or consent. Another resident with cognitive impairment, abnormal gait, Parkinson's disease, and psychosis was found with a geri-chair parked alongside the bed, restricting movement. Staff interviews confirmed that placing the geri-chair in this manner could restrict the resident's ability to get out of bed and potentially lead to entrapment or injury. Staff acknowledged that this practice constituted a restraint and was unsafe for the resident. Facility policy requires that restraints only be used for the safety and well-being of residents, with a physician's order and informed consent, and only after other alternatives have been tried unsuccessfully. The policy also defines physical restraints as any device that restricts a resident's freedom of movement and cannot be easily removed by the resident. The observed practices did not comply with these requirements, as devices were used in ways that restricted residents' movement without proper assessment, documentation, or consent.