Failure to Prevent Use of Physical Restraint Without Assessment or Alternatives
Penalty
Summary
A resident was observed repeatedly confined to a Broda chair, which was reclined at a 45-degree angle with the footrest elevated, preventing the resident's feet from reaching the floor and making it impossible for the resident to exit the chair independently. The resident was visibly agitated, yelling to be let out, attempting to climb over the arm of the chair, and throwing items onto the floor. Staff interviews revealed that the Broda chair was used to prevent falls, as the resident had a history of falling from a standard wheelchair. However, there was no evidence that alternative interventions for fall prevention were attempted prior to the use of the Broda chair. Review of the resident's care plan and medical records showed no documentation of alternative fall interventions, no assessment by physical therapy for the use of the Broda chair, and no physician order for a restraint. The facility did not have a restraint policy or procedure, as it identified itself as a restraint-free facility. Staff confirmed that the use of the Broda chair was not based on a formal assessment or recommendation, and the resident's agitation was attributed to being confined in the chair.