Failure to Prevent Unnecessary Use of Physical Restraints
Penalty
Summary
The facility failed to ensure that two residents were free from the use of physical restraints not required for medical treatment. Both residents were cognitively impaired, required staff assistance for daily care, and used wheelchairs for mobility. According to their care plans and MDS assessments, they were at risk for falls. Observations revealed that both residents were seated at a dining room table with their wheelchair brakes engaged, preventing them from moving away from the table. The residents attempted to move or push away from the table but were unable to do so due to the locked wheelchairs. Staff interviews confirmed that it was common practice to lock the wheelchairs of residents at risk for falls while they were in the dining room. An LPN stated that this was done to prevent falls, and the DON indicated she did not consider this a restraint, despite the restriction of movement. The facility's policy stated that residents should be free from restraints unless needed for medical treatment, but there was no evidence that the use of locked wheelchairs in this context was medically necessary.