Failure to Assess and Prevent Use of Geriatric Chair as Restraint
Penalty
Summary
The facility failed to ensure that staff did not utilize a geriatric chair as a restraint without proper assessment for one resident with a history of falls and severe cognitive impairment. Staff routinely placed the resident in a reclined geriatric chair and positioned the chair along the side of the resident's bed to prevent the resident from getting up without staff's knowledge. This practice was carried out despite the resident's known history of attempting to climb out of the geriatric chair and over it from the bed, and without conducting a pre-restraining assessment or obtaining a physician's order or consent, as required by facility policy. The resident had multiple medical conditions, including cauda equina syndrome, vertebral complications, dementia, bipolar disorder, and a history of falls. The care plan indicated the use of a geriatric recliner for rest periods but did not authorize the use of any type of restraint. Staff interviews revealed that the geriatric chair was intentionally used as a barrier to restrict the resident's mobility, with the wheels locked and the chair placed in a way to alert staff if the resident attempted to get up. Staff and nursing leadership demonstrated inconsistent understanding of when the use of the geriatric chair constituted a restraint, and no assessments were completed to evaluate its use as a restraint for any resident, including this one. An incident occurred in which the resident was found with a facial bruise and later diagnosed with a cervical spine fracture after attempting to climb over the geriatric chair placed beside the bed. The medical director was not informed of the use of the geriatric chair as a barrier and stated that such use was at least an attempt at a restraint. Facility leadership, including the administrator and DON, acknowledged a lack of assessment and monitoring regarding the use of the geriatric chair as a restraint, and the facility's own policy was not followed in this case.