Failure to Obtain Orders, Consents, and Assessments for Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints imposed for discipline or convenience, as evidenced by the lack of required physician orders, consents, and risk assessments for two residents. One resident, admitted with multiple diagnoses including chronic kidney disease and impaired cognition, was observed using a Geri-chair for mobility without documentation of a physician's order, signed consent, or completed risk assessment. The resident's care plan indicated the use of the Geri-chair, but the necessary regulatory steps were not followed. Another resident, with a history of dementia, falls, and severely impaired cognition, was observed using a pommel cushion in a wheelchair. The medical record did not contain a physician's order, consent, or risk assessment for this device, despite its use being documented in the care plan. Interviews with facility staff, including the DON and Administrator, confirmed that the facility had not obtained the required documentation for these restraints and did not have a policy in place for restraints or bed rails.