Resident Restrained in Recliner Without Medical Necessity
Penalty
Summary
A resident with diagnoses including Alzheimer's, dementia, depression, cognitive communication deficit, unsteadiness on feet, and a psychotic disorder with hallucinations was observed in situations that led to the use of a physical restraint. The resident's care plan included interventions such as providing diversions, structured activities, education, close supervision, and regular rounds to address her risk of elopement and wandering. However, during observation, the resident was seen attempting to leave the dining room in her wheelchair and later attempting to get out of a recliner with the footrest extended. A Certified Nursing Assistant (CNA) stated that the recliner was used to keep the resident, who was identified as a wanderer, safely in one place. The CNA confirmed that the resident could not get out of the recliner without assistance. This use of the recliner as a restraint was not documented as a medical necessity and was not part of the resident's care plan interventions, resulting in the resident not being free from physical restraints.