Failure to Assess for Potential Physical Restraint in Cognitively Impaired Resident
Penalty
Summary
The facility failed to assess the potential for the use of a physical restraint for one resident with severe cognitive impairment. The resident, who had diagnoses including dementia and anxiety and scored 4 out of 15 on the BIMS, was admitted with significant cognitive limitations. On one occasion, the resident was observed attempting to get out of a personal recliner chair with the footrest elevated, resulting in a fall and a hematoma to the forehead. The remote to control the footrest was out of reach, and staff confirmed that the resident did not have the cognitive ability to operate the remote independently. Despite facility policy requiring a safety audit of personal chairs for all residents, no such audit or physician restraint assessment had been completed for this resident's chair. The lack of assessment and oversight led to the resident being left unattended in a situation where the chair's configuration limited the resident's ability to rise independently, meeting the definition of a physical restraint as outlined in the State Operations Manual.