Failure to Prevent Unnecessary Physical and Chemical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary physical and chemical restraints. The resident, who had severe cognitive impairment and a history of falls, was administered Haloperidol (Haldol) beyond the physician's ordered timeframe. The medication order was to be discontinued on a specific date, but the medication was still present in the medication cart and being administered after the order had expired. The Director of Nursing confirmed that there was no current physician order for the medication, yet it remained available and in use. Additionally, the resident was subjected to physical restraint without proper assessment or documentation. The care plan included an intervention to apply restraints, and the resident's family member confirmed that consent was given for restraint use after being informed by staff about the resident's aggressive behavior and multiple falls. The family member observed the restraint tied around the resident's abdomen and secured to the bed, which the resident was unable to remove. The resident was also observed to be unresponsive to verbal and physical stimuli and had visible bruises and scabs on both arms and legs. The facility's policy required a pre-restraining assessment, physician order, and documentation of the episode leading to restraint use, none of which were fully adhered to in this case. The policy also specified that restraints should not be used for fall prevention or staff convenience, but only for the treatment of medical symptoms after less restrictive interventions had failed. The Director of Nursing acknowledged that the care plan guides staff actions and that restraints should only be applied with a physician's order after careful monitoring, which was not followed in this instance.