Failure to Individualize and Document Use of Physical Restraints
Penalty
Summary
Facility staff failed to ensure the individualized use of physical restraints for three residents, as required by both facility policy and state regulations. The facility's policy mandates that before a restraint is used, there must be identification of a specific medical symptom, documentation of the duration and monitoring of restraint use, evaluation of less restrictive alternatives, and ongoing re-evaluation of the need for the restraint. However, for all three residents sampled, these requirements were not met. The use of Merry Walkers, which are considered restraints if the resident cannot remove themselves, was not properly assessed, documented, or care planned as restraints. One resident with dementia and severe cognitive impairment was regularly placed in a Merry Walker and could not remove themselves from the device. Staff interviews confirmed that the resident was unable to exit the Merry Walker independently, and the device was not coded as a restraint on the MDS or included in the care plan as such. There was no documentation of risk/benefit discussions with the resident's representative, and the physical therapist had not re-evaluated the need for the device since the initial assessment. The resident experienced a fall while in the Merry Walker, resulting in multiple bruises and a hospital transfer. Two other residents, both with severe cognitive impairment and mobility issues, were also placed in Merry Walkers without proper documentation or individualized assessment. Staff confirmed that these residents could not remove themselves from the devices, and there was no evidence of risk/benefit analysis or ongoing re-evaluation. The devices were not identified as restraints in the residents' records, and the required documentation and care planning were absent. The DON and other staff acknowledged these deficiencies during interviews.