Failure to Assess and Prevent Use of Electric Recliner as Physical Restraint
Penalty
Summary
A deficiency occurred when a resident with intact cognition and multiple medical diagnoses, including cancer, heart failure, and malnutrition, was placed in an electric recliner that functioned as a physical restraint. The resident required assistance with all activities of daily living and was identified as a fall risk. Observations revealed that staff placed the resident in the recliner, elevated the footrest, and then positioned the remote control out of the resident's reach, preventing independent operation of the chair. The care plan did not address the use of the electric recliner, and the electronic health record lacked documentation of an assessment for its use. Interviews with staff confirmed that the resident was unable to get out of the recliner independently and did not know how to use the remote due to cognitive impairment. The facility's policy required a physical device assessment to ensure safe operation of such devices, but no assessment was completed for this resident. The director of nursing acknowledged that without the ability to operate the chair, its use constituted a restraint, and confirmed that the required assessment had not been performed.