Failure to Ensure Resident Free from Physical Restraint Without Physician Order
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease, high blood pressure, and lumbar radiculopathy was found to have their bed placed against the wall without a physician's order or documented medical justification. The facility's policy requires that residents be free from physical restraints unless authorized in writing by a physician for a specific and limited period or in emergencies. In this case, there was no documentation in the resident's clinical record, plan of care, or progress notes to support the use of the bed against the wall as a restraint or to indicate a medical reason for this intervention. The resident in question had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Despite this, there was no evidence of a physician's order or care plan goal related to the bed placement. During staff interviews, it was confirmed that the facility failed to ensure the resident was free from the use of a physical restraint without proper authorization, as required by both facility policy and state regulations.