Failure to Assess and Document Use of Wheelchair Seatbelt as Physical Restraint
Penalty
Summary
Staff failed to ensure an environment free from physical restraints for a resident who used a motorized wheelchair with a seatbelt. The resident, who had diagnoses including COPD and atrial fibrillation and demonstrated intact cognition, was observed wearing a seatbelt that he could not independently release. Documentation in the electronic health record, care plan, and physician orders did not address the use of the seatbelt, nor was there evidence of an assessment of the resident's ability to release it. Staff interviews confirmed that the resident was required to wear the seatbelt, was unable to remove it on his own, and that no seatbelt safety assessment or care plan was in place for any resident. The resident reported he was told he had to wear the seatbelt and did not have a choice in the matter. Observations showed the seatbelt remained engaged for extended periods, and staff were responsible for applying and releasing it. Staff also indicated that not all residents required seatbelts and that it was policy for residents using electric wheelchairs to wear them, but there was no clear process for evaluating whether a seatbelt constituted a restraint. The facility's policy required a practitioner's order for a restraint, but no such order or documentation was present for the seatbelt. The lack of assessment, documentation, and resident choice led to the use of a physical restraint without proper justification or oversight.