Failure to Release Physical Restraint and Document Required Intervals
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints imposed for discipline or convenience. Observations revealed that the resident, who had severe cognitive impairment and diagnoses including Parkinson's disease, psychosis, restlessness, and anxiety, was consistently seated in a geri-chair with a lap tray in place. The resident was unable to remove the lap tray independently, and staff confirmed that the tray was not being released every two hours as required by facility policy. There was no physician's order or documentation for the scheduled release of the lap tray to allow for range of motion or repositioning. Interviews with facility staff, including a CNA, LPN, DON, corporate consultant, and RN administrator, confirmed a lack of awareness and documentation regarding the need to release the lap tray every two hours. The facility's policy requires that restrained residents be given the opportunity for motion and exercise for at least ten minutes every two hours and be repositioned on all shifts, but these actions were not documented or carried out for this resident. The absence of both a physician's order and documentation of required releases constituted a failure to comply with restraint use protocols.