Failure to Assess and Document Use of Wheelchair Brakes as Restraints
Penalty
Summary
The facility failed to ensure that two residents were free from the use of physical restraints, specifically the use of locked wheelchair brakes, without proper assessment or physician orders. Both residents had significant cognitive impairments, including dementia, and required varying levels of assistance with mobility and transfers. Despite this, their care plans and medical records did not indicate any assessment to determine if they could independently unlock their wheelchair brakes, nor were there orders for the use of locked brakes as a restraint. During observations, both residents were found in the common area with their wheelchair brakes locked, restricting their ability to move. One resident attempted to stand and propel the wheelchair but was unable to do so due to the locked brakes, resulting in repeated unsuccessful attempts to move or stand. The other resident, who was dependent on others to lock or unlock the brakes but could self-propel, was also unable to move the wheelchair or reach for support due to the brakes being locked. Staff interviews revealed uncertainty about whether these residents could unlock their brakes and whether the use of locked brakes was part of their care plan. Further interviews with nursing staff and the DON confirmed that wheelchair brakes should not be locked unless the resident can unlock them, as this would otherwise constitute a restraint. The facility's own policy required a comprehensive assessment, education on risks and benefits, and a physician's order for the use of physical restraints, none of which were documented for these residents. The lack of assessment and documentation led to the inappropriate restriction of movement for both residents.