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F0604
D

Failure to Assess and Document Physical Restraint Use

Palmyra, Pennsylvania Survey Completed on 06-06-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to properly assess and document the use of a physical restraint for one resident with severe intellectual disabilities, anxiety, and lack of coordination. Over multiple days of observation, the resident was seen in a wheelchair with a seat belt that she could not self-remove. Staff confirmed the resident's inability to remove the seat belt independently. There was no documented evidence that a physician's order or rationale for the restraint was obtained, nor was there an initial or ongoing assessment of the restraint's necessity, as required by facility policy. The interdisciplinary team did not develop a comprehensive care plan for the restraint, and monthly reevaluations were not documented.

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