Failure to Document and Justify Use of Physical Restraint (Wander Guard)
Penalty
Summary
The facility failed to follow its own policy and procedure regarding the use of physical restraints, specifically in the application and documentation of a wander guard device for a resident. The resident in question was admitted with diagnoses including hemiplegia following a stroke, aphasia, and severe cognitive impairment. Despite the resident's cognitive status, multiple assessments and monitoring sheets indicated that the resident did not exhibit wandering behavior during their stay, and there were no documented episodes of elopement or attempts to leave the facility. Physician orders were in place for the use of a wander guard, and the resident was monitored hourly, but documentation supporting the ongoing need for the device was inconsistent. The resident's care plan and risk assessments fluctuated, at times indicating risk for elopement and at other times not, without clear rationale documented for these changes. Staff interviews confirmed that the resident refused to wear the wander guard and that there were no observed incidents of wandering or exit-seeking behavior. The facility's policy classified the wander guard as a physical restraint, requiring specific documentation and justification for its use, which was not consistently present in the resident's record. The lack of proper documentation and justification for the use of the wander guard, as required by facility policy, resulted in a deficiency. Staff and leadership acknowledged that the absence of supporting documentation for the restraint could violate the resident's rights and potentially result in psychological harm. The facility's own policies also required that episodes of wandering or exit-seeking behavior be documented in the medical record, along with the interventions used and their effectiveness, which was not done in this case.