Failure to Document and Re-Evaluate Ongoing Use of Physical Restraints
Penalty
Summary
The facility failed to ensure proper documentation and ongoing evaluation for the use of physical restraints on a resident with multiple complex medical conditions, including acute respiratory failure, COPD, encephalopathy, ventilator dependence, and significant cognitive impairment. The resident was admitted with a history of attempting to remove life-sustaining medical equipment, leading to the use of mitt restraints as ordered by the provider. However, the provider order lacked essential details such as the specific diagnosis justifying the restraint, instructions for breaks in restraint usage, and requirements for monitoring the effectiveness of less restrictive interventions. Nursing progress notes indicated that mitt restraints were applied and skin assessments were performed on select dates, but there was no consistent documentation of the ongoing need, usage, or evaluation of the continued use of restraints as required by facility policy. The care plan did not include specific goals or interventions related to the mitt restraints, nor did it address ongoing monitoring or plans for removal. The Medication Administration Record showed that mitt restraints were signed off for each shift, but this did not substitute for the required comprehensive documentation and evaluation. Interviews with facility staff, including the DON, respiratory therapist, nurse practitioner, and LPN, revealed a lack of clarity and consistency in the documentation and management of restraints. Staff acknowledged the need for restraints due to the resident's behaviors but confirmed that there was no daily checklist or structured process for documenting alternatives attempted, ongoing re-evaluation, or effectiveness of the restraint. The facility's own policy required documentation of medical symptoms warranting restraint use, less restrictive alternatives, and ongoing re-evaluation, none of which were adequately present in the resident's record.