Failure to Document Indication for Physical Restraint Use
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints by not including a required indication for the use of bilateral hand mittens in the physician's order. The resident, who was admitted with diagnoses including encephalopathy, hypertension, and diabetes, was cognitively impaired and dependent on staff for activities of daily living. The physician's order for hand mittens specified their use and monitoring requirements but did not state the reason for their use, as required by the facility's policy. During interviews and record reviews, both the Registered Nurse Supervisor and the Interim Director of Nursing confirmed that the physician's order was incomplete due to the missing indication. They stated that the absence of a documented reason for the mittens could lead to inadequate communication among staff, the provider, and the resident's family, and could prevent staff from properly monitoring the resident's behavior and the need for the restraint. The facility's policy required that orders include the reason or problem for which they are given, which was not followed in this case.