Failure to Ensure Resident Remained Free from Physical Restraints
Penalty
Summary
Facility staff failed to ensure that a resident was free from physical restraints, as required, by placing the resident in a Geri chair with a hard table cover that prevented the resident from moving freely or getting in and out of the chair independently. The resident, who had diagnoses including essential primary hypertension, nontraumatic intracerebral hemorrhage, and mild cognitive impairment, was unable to remove the tray or exit the chair without staff assistance. Staff interviews confirmed that the Geri chair was used to prevent falls due to the resident's generalized weakness and high fall risk, and that the resident could not get out of the chair on his own once placed in it. Record review showed that the resident's care plan only referenced the use of the Geri chair for safety, comfort, and mobility support, but did not include other interventions for fall risk or muscle weakness. Observations on multiple occasions confirmed the resident was restrained in the Geri chair with a tray, and staff acknowledged that the resident could not remove the tray or leave the chair independently. Facility policy identified the Geri chair as a restraint and required documentation of all measures tried prior to restraint use, but such documentation and alternative interventions were not present in the resident's care plan.