Failure to Release and Evaluate Use of Velcro Seatbelt Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, specifically by not releasing a Velcro self-releasing seatbelt during supervised activities and meals, and by not evaluating or documenting the resident's ability to self-release the seatbelt every shift. The resident, who had diagnoses including metabolic encephalopathy, repeated falls, and unspecified dementia, was observed multiple times with the seatbelt secured while under direct supervision during meals and activities. Despite the facility's policy requiring restraints to be used only when necessary for medical symptoms and to be the least restrictive option, the seatbelt remained in place even when the resident was supervised and not exhibiting impulsive behaviors. Additionally, the care plan and physician's orders required staff to prompt and document the resident's ability to self-release the seatbelt every shift, but nursing progress notes did not show evidence of this documentation. Interviews with facility leadership confirmed that the resident's ability to self-release was inconsistent and that required quarterly restraint assessments were not completed as scheduled. The DON acknowledged that the seatbelt should have been considered a restraint due to the resident's fluctuating mental status and inconsistent ability to self-release.