Failure to Assess Resident for Use of Physical Restraint
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was appropriately assessed for the use of a physical restraint. The resident, who had a history of stroke and was impaired on one side, used a motorized wheelchair with a self-releasing seatbelt. According to the facility's policy, an evaluation should be completed prior to the initiation of any device that could function as a restraint, as well as annually and upon a change of condition. However, a review of the resident's electronic medical record revealed that no assessment was completed regarding the use of the seatbelt when the resident used the motorized wheelchair. Observations over several days showed the resident moving throughout the facility in the wheelchair with the seatbelt in place. Interviews with the resident and multiple staff members indicated that the seatbelt was used for safety, but the resident could not latch it independently, though they could unlatch it. Staff confirmed that an assessment was required in such cases to determine if the seatbelt was functioning as a restraint, but were unsure if one had been completed. The Director of Nursing Services was unaware of the seatbelt use until recently and stated that assessments should be completed quarterly to ensure the seatbelt was not acting as a restraint.