Failure to Assess and Document Use of Restraints and Assistive Devices
Penalty
Summary
The facility failed to perform and document complete resident assessments prior to the use of physical restraints or assistive devices that could be considered restraints for several residents. In one case, a resident with left-sided paralysis and limited hand mobility had upper bed rails in place, which he could not lower independently. Staff and the resident indicated the bed rails were used to prevent falls and assist with mobility, but documentation did not show whether the bed rails met the criteria for a restraint or if risks and benefits were discussed with the resident or representative. The assessments also failed to indicate if the resident could remove the bed rails independently, despite staff statements that the rails restricted his ability to get out of bed. Another resident was observed using a scoop mattress, which she stated did not restrict her movement and was used to assist with transfers and positioning due to poor core control. However, the facility did not complete or document an assessment prior to the initial use of the scoop mattress, nor did they provide ongoing monitoring of its use. The evaluation on file did not address whether the scoop mattress limited the resident's freedom of movement, and there was inconsistency in the documentation regarding whether it was considered a restraint. A third resident was observed with bed rails in the up position, which she stated helped prevent her from falling out of bed. Staff confirmed the bed rails were used for safety, and the resident was able to get out of bed independently. However, there was a lack of documented Assistive Device/Restraint Evaluations for an extended period, indicating a failure to perform ongoing monitoring of the use of bed rails as required. The facility's policy defined restraints based on the resident's ability to remove the device and its impact on freedom of movement, but the required assessments and documentation were incomplete or missing for the residents involved.