Failure to Complete Required 30-Day Restraint Evaluations
Penalty
Summary
The facility failed to complete an evaluation every 30 days for the ongoing use of a restraint for one resident. According to the facility's policy, the interdisciplinary team is required to review and reevaluate the use of all restraints ordered by a physician or their designee at least every 30 days. For the resident in question, who had diagnoses including dementia and Down syndrome, there were physician orders and care plan interventions for the use of a one-piece dignity suit at night to address behavioral symptoms such as smearing and ingesting feces. The initial equipment assessment and consent for the dignity suit were completed, and follow-up assessments were documented on two occasions several months apart. However, the clinical record review revealed that the required 30-day ongoing evaluations for the restraint were not consistently completed. The Nursing Home Administrator confirmed that although an ancillary order for monthly evaluations was entered, it did not populate in a way that ensured completion. As a result, the facility did not meet its own policy or regulatory requirements for regular restraint evaluation for this resident.
Plan Of Correction
1. R 27's dignity jumpsuit was evaluated on 12/9/25. A physician treatment order was obtained 12/9/25 to complete an evaluation every 30 days. 2. A review of current residents reveals that no other residents have been identified as utilizing restraints. 3. Licensed staff will be re-educated on restraints, proper documentation, and evaluations every 30 days for ongoing use of restraints. 4. The Director of Nursing or designee will audit residents with restraints weekly for 12 weeks to validate that evaluations of the restraint are completed every 30 days. Findings of audits will be analyzed to identify/track trends or patterns and will be reported to the facility Quality Assurance/Performance Improvement Committee for review and/or recommendation.