Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
A deficiency occurred when a resident with dementia, seizure disorder, psychotic and mood disturbances, and moderate cognitive impairment was placed in a Broda chair with the brakes engaged while seated at the dining table. The brakes, located on the back lower wheels of the chair, were not accessible to the resident, preventing her from moving the chair independently. Multiple observations by the surveyor confirmed that the resident remained in this position for an extended period, attempting unsuccessfully to move the chair by grabbing the wheels, but was unable to do so due to the locked brakes. Interviews with facility staff revealed inconsistent understanding regarding the resident's ability to self-propel in the Broda chair and whether locking the brakes constituted a restraint. The facility's own policy defines a physical restraint as any device that restricts freedom of movement and cannot be easily removed by the resident. Despite this, the resident was repeatedly observed with the brakes engaged, restricting her movement, and staff acknowledged that this could be considered a restraint. The care plan indicated the resident required assistance with mobility and had a history of falls, but did not specify the use of restraints for medical treatment.