Failure to Ensure Residents' Right to Be Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless required for medical treatment, as evidenced by multiple observations, interviews, and record reviews involving four residents. For two residents, staff placed pillows tightly tucked under the fitted sheet on both sides of the bed, which restricted the residents' freedom of movement. These actions were performed for staff convenience and without a physician's order, informed consent, physical restraint assessment, or inclusion in the care plan. Both the Director of Staff Development and the Director of Nursing confirmed that this practice was not permitted, as it prevented residents from moving freely and could be considered a restraint. Another resident was found to be using a low air loss mattress with built-in bilateral upper and lower bolsters for trunk control and postural positioning. However, there was no documentation of a physician's order, informed consent, physical restraint assessment, or care plan for the use of these bolsters. The MDS Coordinator and DON acknowledged that the use of bolsters in this manner could be considered a restraint, as it restricted the resident's movement, and that the required assessments and documentation had not been completed. A fourth resident's bed was placed against the wall to prevent falls, but this intervention was implemented without a physician's order, informed consent, restraint assessment, or care plan. Staff interviews confirmed that these steps were necessary to ensure the safe use of such interventions and to honor the resident's right to informed consent. The facility's own policies required that before any restraint is used, alternative methods must be attempted and documented, and that a comprehensive assessment, physician's order, informed consent, and care plan must be in place, none of which were completed in these cases.