Failure to Assess and Document Use of Wheelchair Seatbelt as a Restraint
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess the use of a restrictive device as a potential restraint for a resident with intact cognition and diagnoses including anemia, hemiparesis, and multiple sclerosis. The resident required extensive assistance with activities of daily living, used a wheelchair for mobility, and had a high risk for falls. Despite documentation in the Minimum Data Set, Care Area Assessment, and care plan indicating no use of restraints, observations revealed the resident was consistently seated in a motorized wheelchair with a seatbelt fastened around her waist. The resident was unable to remove the seatbelt independently and stated it made movement difficult, while staff confirmed the seatbelt was used to prevent her from sliding or falling out of the wheelchair. Interviews with nursing staff and the acting director of nursing confirmed that the seatbelt restricted the resident's movement and that she could not remove it herself, meeting the facility's own definition of a physical restraint. However, there was no evidence in the medical record of a restraint assessment, physician order, or care plan documentation regarding the seatbelt's use as a restraint. The facility's policy required assessment of any device that could be considered a restraint, but this was not completed for the resident in question.