Failure to Ensure Residents' Rights and Proper Use of Physical Restraints
Penalty
Summary
Surveyors identified multiple deficiencies related to the improper use of physical restraints and failure to ensure residents' rights to dignity and freedom of movement. In several cases, side rails were raised on both the upper and lower sides of beds without proper assessment, physician orders, or informed consent. For example, one resident was found with all four side rails raised, despite only having an order and assessment for bilateral upper side rails. Staff interviews confirmed that the lower side rails were raised without authorization, and there was no documentation of an assessment for their safety or need. The facility's own policies require assessment, informed consent, and physician orders prior to the use of restraints, which were not followed in these instances. Another deficiency involved the use of pillows and blankets as physical barriers under a resident's fitted sheet, which was not ordered or care planned. Staff acknowledged that this practice was not standard and could restrict the resident's movement, effectively acting as a restraint. Additionally, for another resident, required entrapment risk assessments and quarterly restraint assessments for the use of side rails were not completed as mandated by facility policy. Staff interviews confirmed that these assessments were missing for multiple review periods, and the use of both upper and lower side rails was not properly evaluated for safety or necessity. Further deficiencies were found in the use of tab alarms for two residents. These alarms, which are considered restraints, were applied without obtaining informed consent or completing initial and quarterly restraint assessments. Staff confirmed that the alarms were in use to prevent falls, but the required documentation and evaluation for their appropriateness and safety were not completed. Facility policies reviewed by surveyors clearly state that restraints, including alarms, require a physician's order, informed consent, and ongoing assessment, none of which were consistently documented or performed in these cases.