Failure to Maintain Environment Free of Physical Restraints
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and a diagnosis of severe dementia with agitation was found physically restrained in a wheelchair using a gait belt. The resident, who had a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment, was observed by staff with a gait belt wrapped around their waist and the wheelchair, effectively restraining them. Multiple staff members, including GNAs, LPNs, and an occupational therapist, observed or were informed about the restraint, and photographic evidence was taken and shared among staff. Medical record review confirmed that the resident was not care planned for restraint use, and there was no physician order authorizing the use of restraints. Witness statements revealed that the gait belt was left on the resident for an extended period, and several staff members became aware of the situation but did not immediately remove the restraint or report the incident to appropriate supervisory personnel. The occupational therapist and other staff acknowledged in hindsight that the restraint should have been removed sooner. The incident was further substantiated by text messages and emails among staff and administration, including photographic documentation of the resident restrained in the wheelchair. Despite multiple staff being aware of the restraint, there was a delay in action, and the individual responsible for applying the restraint could not be identified. The resident was later observed without the restraint, but the deficiency was established based on the failure to maintain an environment free from physical restraints as required.