Failure to Ensure Proper Authorization and Monitoring of Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by policy and regulation. A resident with a history of CVA and left-sided hemiparesis was observed multiple times with a soft mitten restraint on the right hand. There was no active physician's order, updated informed consent, or current care plan authorizing the use of the restraint. The resident's medical record indicated that previous orders and consents for the mitten restraint had been discontinued years prior, and the care plan addressing the restraint had been resolved. Additionally, the resident's medication administration record did not show any current monitoring for the use of the restraint. Staff interviews confirmed that the soft mitten was being used without the necessary documentation, assessment, or monitoring. Both LVN and RN staff acknowledged that the facility's policy required a physician's order, family consent, care plan, and regular monitoring for restraints, none of which were in place for this resident. The administrator also acknowledged these findings. The lack of appropriate assessment, documentation, and monitoring for the use of the restraint constituted a failure to provide an environment free from unnecessary physical restraints.