Failure to Assess and Document Wheelchair Seatbelt Use as Potential Restraint
Penalty
Summary
A deficiency occurred when a resident with dementia, traumatic brain injury, legal blindness, and unsteadiness was found using a wheelchair with a seatbelt that had not been properly assessed as a potential restraint. The facility's policy required a pre-restraining assessment and ongoing review to determine the need for restraints and to consider less restrictive interventions. However, there was no documentation of a physician's order for the seatbelt, no mention of the seatbelt in the resident's care plans, and no completed restraint assessment in the medical record. Staff interviews revealed uncertainty regarding whether a restraint assessment had ever been completed for the seatbelt, and the DON acknowledged that a formal assessment should have been done upon admission and periodically thereafter. The resident was unable to explain the purpose or duration of the seatbelt use, and staff were unclear about the requirements for restraint assessment, leading to a failure to ensure the resident was free from unnecessary restraints as required by facility policy.