Failure to Assess and Document Use of Positioning Devices and Alarms as Potential Restraints
Penalty
Summary
The facility failed to properly assess and document the use of adaptive equipment and pressure alarms for four residents who were reviewed for physical restraints. For one resident with frontotemporal dementia and a history of falls, a positioning device (lap buddy) and bed alarm were used without a restraint assessment or physician's order. Staff interviews revealed that the resident was physically strong but unable to intentionally remove the device, and the therapy director confirmed that recommendations for such devices were not routinely made for most residents. Another resident with dementia, traumatic brain injury, and seizure disorder was observed with a positioning device in place, but there was no restraint assessment in the medical record. The resident was unable to demonstrate the ability to remove the device independently. The MDS Coordinator stated that restraint assessments were not performed for these devices, as they were not considered restraints by the facility, and believed the devices would release when the resident stood up. Two additional residents, one with a history of fracture, aphasia, and muscle weakness, and another with anxiety, depression, and altered mental status, were both using bed and/or chair alarms as fall interventions. In both cases, there were no physician's orders or assessments for the alarms in the medical records. Staff interviews confirmed that alarms were implemented without orders or assessments, and the facility did not have a policy regarding physical restraints.