Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required, unless needed for medical treatment. The resident in question had severely impaired cognition, multiple neurological diagnoses including Parkinson's disease and dementia, and was dependent on staff for mobility and transfers. Despite these needs, the resident was regularly placed in a recliner in the common area with the feet elevated and the remote control out of reach, which restricted the resident's ability to get up independently. Staff interviews confirmed that the resident could not activate the chair and could not get up from the recliner without assistance. Documentation and care planning did not include a medical diagnosis or assessment justifying the use of the electric recliner as a restraint, nor was there an order for its use. The care plan addressed fall risk and mobility deficits but did not specify the use of the recliner as a restraint or include an assessment of the resident's ability to rise from it. Occupational therapy and the director of therapy confirmed that no assessment had been completed regarding the safety or appropriateness of the recliner for this resident, and the use of the recliner was not evaluated as a physical restraint. Family members and staff interviews indicated that the recliner was used as a means to prevent falls after bed alarms could no longer be used, and that no consent or waiver was signed for its use. Facility policy defined physical restraints as any device that restricts freedom of movement and cannot be easily removed by the resident, and required evaluation for such devices. The lack of assessment, documentation, and proper authorization led to the use of the recliner in a manner that restricted the resident's freedom of movement, constituting a deficiency in compliance with restraint regulations.