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F0552
D

Failure to Obtain Informed Consent for Use of Physical Restraint

Sunland, California Survey Completed on 12-04-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that informed consent was obtained from a resident's responsible party prior to the use of a physical restraint, specifically a wander guard device, for a resident with severe cognitive impairment and no decision-making capacity. The resident was admitted with diagnoses including hemiplegia following a stroke and aphasia, and was assessed as severely impaired in cognition and unable to make decisions. Despite this, the initial informed consent form for the wander guard indicated the resident was self-responsible and unable to sign, as the facility was unaware of any family at the time. After the facility became aware that the resident had family, there was no documented attempt to obtain written consent from the responsible party, even though the facility's policy required informed consent from the resident or legal representative for the use of physical restraints. The interdisciplinary team attempted to contact the family for a care plan meeting, but the family did not respond or attend. The facility's policies also required that residents or their representatives receive all information regarding risks, benefits, and alternatives to proposed care, including the use of restraints, in advance.

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