Failure to Prevent Unauthorized Use of Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints not required for medical treatment. According to facility policy, residents who may require restraints must be evaluated for the least restrictive device, considering physical and medical issues and possible alternatives. In this case, a resident with Alzheimer's disease, severe cognitive impairment, and a high risk for falls was admitted and care planned for various interventions, but there was no documentation or care plan indicating the use of a restraint. The Minimum Data Set (MDS) also did not indicate restraint use. Despite this, the resident was observed by an occupational therapist and the Director of Care Coordination with a gait belt fastened around their waist and buckled behind their back while seated in a wheelchair. Facility documentation and an incident report confirmed this observation, and the gait belt was subsequently removed by the Maintenance Director. Interviews with staff revealed that restraints were not used in the memory unit, and gait belts were typically only used by therapy staff. A hospice CNA was identified as the individual who placed the gait belt on the resident.