Failure to Ensure Residents' Right to Be Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless required for medical treatment, as evidenced by the care of two residents. For one resident with schizoaffective disorder, major depressive disorder, and seizures, the facility placed the bed against the wall as a fall prevention measure. Although there was a physician's order for this intervention, the facility did not complete the required quarterly restraint assessments to evaluate the continued appropriateness of this measure, as mandated by facility policy and the resident's care plan. The only documented restraint assessment was from several months prior, and both the Assistant Director of Nursing and the Director of Nursing confirmed that quarterly assessments were not performed as required. Another resident, diagnosed with sepsis, schizoaffective disorder, dementia, and major depressive disorder, was found with pillows tucked under the fitted sheet on one side of the bed, with the bed itself against the wall on the other side. This intervention was implemented by a CNA to prevent falls, but there was no physician's order or care plan documentation supporting this practice. The CNA stated that they believed this was not a restraint, but facility policy and the ADON clarified that tucking pillows under the fitted sheet is considered a restraint and is not permitted, as it restricts the resident's freedom of movement. Both cases demonstrated a lack of adherence to the facility's own policies and procedures regarding the use of physical restraints. The required interdisciplinary team discussions, documentation, and ongoing evaluations were not completed for the use of the bed against the wall, and unauthorized restraint practices were implemented without proper assessment or documentation for the use of pillows under the fitted sheet. These actions resulted in the restriction of residents' freedom of movement and did not honor their right to be free from physical restraints.