Failure to Assess and Document Use of Physical Restraint
Penalty
Summary
A deficiency occurred when a resident with cerebral palsy, severe intellectual disabilities, and aphasia was found using a wheelchair seat belt that she was unable to remove. Observations confirmed that the seat belt was secured across her lap, and both a CNA and an LPN verified that the resident could not remove it herself. The seat belt had been in use since the resident's admission, and staff stated it was used to prevent falls. The resident's cognitive assessment indicated severely impaired decision-making abilities, and she was unable to complete a mental status interview. Record review revealed there was no physician order for the seat belt, and the resident's care plan did not address its use. The MDS assessment did not code the resident as using restraints. The facility's policy requires an interdisciplinary team assessment, consideration of less restrictive alternatives, and proper documentation before using restraints, none of which were completed in this case. The DON confirmed that the seat belt was used without assessment, care planning, or a physician order.