Failure to Ensure Resident's Right to Be Free from Physical Restraints
Penalty
Summary
A resident with a left below-the-knee amputation was observed with their stump secured to a wheelchair footrest using a tan compression wrap, which the resident was unable to remove independently. Staff interviews revealed that the compression wrap had been used for some time to keep the stump in place because the resident would not wear their prescribed brace. Multiple staff members acknowledged that there was no physician's order for the use of the compression wrap as a restraint, and no assessment or documentation was completed regarding its use. Staff also indicated a lack of awareness about the need for documentation or assessment, and some staff were under the impression that securing the stump in this manner was permissible. Record reviews confirmed the absence of a physician's order, assessment, or documentation related to the use of the compression wrap as a restraint. There was no evidence of monitoring, release, or skin assessment for the area where the wrap was applied. Additionally, therapy evaluations did not address the use of the compression wrap for stump positioning. The facility's own policy prohibits the use of physical restraints without proper assessment, documentation, and physician authorization, none of which were present in this case.