Failure to Follow Protocols for Use of Physical Restraints
Penalty
Summary
The facility failed to ensure that three residents were free from the use of physical restraints without proper procedures, including obtaining a physician's order, informed consent, and conducting a restraint assessment. For one resident with a history of falls, impaired cognition, and limited mobility, the bed was placed against the wall, restricting bed exit and entry to one side. There was no physician's order, informed consent from the resident or representative, restraint assessment, or care plan for this intervention, despite the resident's inability to make decisions and high risk for falls. Two other residents, both with significant cognitive impairment and high fall risk, had pad/tab alarms applied to their beds. These alarms, considered restraints by facility staff and policy, were used to alert staff when the residents attempted to get out of bed. In both cases, there was no physician's order, no informed consent, no restraint assessment, and no care plan developed prior to the application of the alarms. Staff interviews confirmed that these steps were not taken and acknowledged the alarms' restrictive nature. The facility's own policy requires a physician's order, informed consent, and a restraint assessment before applying any restraint, as well as the development of a care plan addressing the use and reduction of restraints. Despite these requirements, the necessary documentation and assessments were not completed for the residents in question, resulting in the use of restraints without adherence to established protocols.