Failure to Ensure Resident Was Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, specifically regarding the use of a seat belt that the resident could not remove independently. The resident, who had diagnoses including dementia, schizophrenia, and seizure disorder, was assessed as being dependent on staff for self-care and mobility, with severely impaired cognitive skills. The care plan initially included a Velcro seat belt for safety, but after multiple unwitnessed falls, the seat belt was changed to a buckle type, which the resident was unable to remove on their own. Despite the change to a buckle seat belt, there was no physician order specifying the medical symptom, frequency of use, release times, or activities to be performed during release. The care plan was updated to reflect the change in seat belt type, but there was no documentation on how the restraint would treat a medical symptom, nor was there evidence of direct monitoring, recommendations for gradual reduction, or assessment of risks related to restraint use. Additionally, there was no documentation of consent obtained from the resident's representative for the use of the buckle seat belt, and no completed restraint assessments after the initial evaluation. Interviews with facility staff revealed a lack of clarity and communication regarding the use and type of seat belt, with some staff unaware of the change or the requirements for restraint use. The facility's own policy requires a specific process for restraint use, including physician orders, consent, regular reassessment, and care planning, none of which were followed in this case. The DON confirmed that the restraint policy was not adhered to because the seat belt was not considered a restraint by the facility.