Failure to Identify and Document Use of Physical Restraint
Penalty
Summary
The facility failed to ensure a resident's right to be free from physical restraints by not identifying and documenting the use of a soft belt as a restraint. During observation, a resident with a diagnosis of Alzheimer's Disease and a BIMS score of 00, indicating severely impaired cognition, was seen in a wheelchair with a Velcro soft belt secured across her lap. The resident was unable to remove the belt upon request. Staff interviews confirmed that the belt was used to prevent the resident from sliding or falling out of the wheelchair and that the resident could not remove it independently. The belt was applied daily, removed for naps, and released every two hours for care needs. A review of the facility's policy indicated that soft belts are considered restraints under any circumstance and require documentation, physician orders, and consent after alternatives have been tried unsuccessfully. However, there was no documentation in the resident's medical record identifying the soft belt as a restraint, nor any evidence of evaluations, orders, consent, or monitoring related to its use. The DON and Administrator both acknowledged the resident's inability to remove the belt and the lack of documentation, but the device had not been previously identified or managed as a restraint.