Failure to Follow Restraint Protocols for Resident Using Hand Mitten
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints by applying a right hand mitten without following required procedures. The resident, who lacked capacity to make decisions, was observed with a mitten on her right hand and bilateral bedrails in place. Staff interviews confirmed that the mitten was used to prevent the resident from pulling at her tracheostomy. However, a review of the medical record revealed there was no physician's order, no documented consent from the resident's representative, and no completed assessment prior to the application of the mitten. Additionally, there was no evidence that less restrictive interventions were attempted before using the restraint. Further review showed that the facility did not initiate a care plan addressing the use of the right hand mitten for the resident. The facility's policy requires a pre-restraining assessment, physician order, consent, and care planning for any restraint use, none of which were completed in this case. Interviews with staff and the resident's family member confirmed that consent was not obtained and the family was not informed prior to the application of the mitten. The Administrator and DON acknowledged these findings during the survey.