Failure to Assess and Obtain Orders for Use of Physical Restraints
Penalty
Summary
Two residents were found to be placed in Geri chairs, which are considered physical restraints, without the required assessments or physician's orders. Both residents had significant cognitive impairments and required varying levels of assistance with daily activities. Observations confirmed that each resident was seated in a Geri chair in the hallway or their room, and staff interviews revealed that the chairs were used to prevent the residents from getting up unassisted, as it was more difficult for them to rise from a Geri chair compared to a wheelchair. Record reviews for both residents showed no documentation of a restraint assessment prior to the use of the Geri chair, nor was there a physician's order authorizing its use. Staff, including a CNA and Registered Nurse Supervisors, acknowledged that the Geri chair limited the residents' movement and that proper procedures, such as assessment and obtaining a physician's order, had not been followed. The facility's own policy also identified Geri chairs as potential restraints and required a pre-restraining assessment and a written physician's order before use. The failure to conduct assessments and obtain physician's orders for the use of Geri chairs resulted in the use of physical restraints without proper justification or documentation. This practice limited the residents' mobility and did not comply with regulatory requirements or the facility's policy regarding the use of restraints.
Plan Of Correction
Immediate Corrective Action for resident affected by this deficient practice; DON added on EHR Restraint-Physical assessment and attained consents and orders for residents 81, 86, 85, 77. Plan /Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken; Admission assessment will include 19. Physical Restraint Initial/Quarterly/Annual. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur; DON and or designee will add to her Chart Review to include Restraint Physical assessment which is done initially and Quarterly, annually with IDT members. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Beginning 7/01/25, DON or designee will review Performance and report to Administrator and report to QAPI monthly meetings for compliance. Monthly QA discussion will occur for 3 months.