Failure to Assess and Document Use of Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, specifically by not identifying a seatbelt as a restraint, not assessing the safety or clinical need for its use, and not obtaining a physician's order or consent prior to its application. Observations showed the resident was seated in a wheelchair with a seatbelt in use, and interviews with staff revealed inconsistent knowledge regarding the resident's ability to remove the seatbelt and the rationale for its use. Some staff believed the resident could remove the seatbelt independently, while others stated she could not. Staff were also unaware of the reason for the seatbelt's use, and the resident's family had not been notified or given consent for its placement. Record review indicated there was no physician's order for the seatbelt, and the resident's MDS assessment did not document the use of restraints. The resident was assessed as rarely or never understood, indicating significant cognitive impairment. Occupational therapy evaluation noted the resident had considerable balance impairments and was at high risk for falls, but did not demonstrate a clinical need for a seatbelt at the time of assessment. The seatbelt was in use without proper assessment, documentation, or consent, resulting in the resident being restrained to her wheelchair without a clinical rationale.