Failure to Develop and Implement Care Plan for Physical Restraint Intervention
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was subject to a physical restraint intervention. Specifically, the resident, who had diagnoses of hemiplegia, hemiparesis following cerebral infarction, and muscle weakness, was admitted with high fall risk and required assistance with mobility and activities of daily living. The resident's bed was placed against the wall as a fall prevention measure, which the Director of Staff Development (DSD) identified as a form of restraint that limited the resident's freedom to exit the bed from both sides. Despite this intervention, there was no corresponding care plan documented in the resident's electronic medical record addressing the use of the bed as a restraint. Further review of the resident's records, including the admission record, history and physical, Minimum Data Set (MDS), and order summary, confirmed the absence of a physician's order or care plan for the restraint intervention. Interviews with facility staff, including the DSD and Assistant Director of Nursing (ADON), revealed that the lack of a care plan led to potential miscommunication among the interdisciplinary team and could result in substandard care. The facility's policy required that a comprehensive care plan be developed within seven days of the baseline assessment, but this was not completed for the restraint intervention used for this resident.