Resident Restrained by Chair Placement Against Bed
Penalty
Summary
A deficiency was identified when a resident was found physically restrained in bed by the placement of a Geri-chair and a regular chair against her bed, blocking her ability to get out on one side. The facility's policy states that residents have the right to be free from physical restraints unless required for medical treatment, and that assessment and consent are required prior to restraint use. The resident in question was severely cognitively impaired, had an impairment in one lower extremity, required substantial to maximum assistance with activities of daily living, and had a history of falls. There was no documentation in the care plan indicating a need for restraint. Multiple staff interviews confirmed that the chairs were intentionally placed to prevent the resident from climbing out of bed, but this was not reported or documented as a restraint. Observations on several occasions showed the chairs blocking the resident's exit from bed. Some staff recognized this as a potential restraint, while others did not report it. The Health Information Manager and other staff had previously noticed and moved the chairs, but the practice continued. The DON stated she had not observed this before and expected staff to report such situations.