Failure to Prevent Unnecessary Use of Physical Restraint
Penalty
Summary
A deficiency occurred when a resident was found seated in a wheelchair with a self-releasing belt applied around the chest-abdominal area. Despite the belt being labeled as 'self-releasing,' the resident was unable to remove it independently and could not follow commands to do so, as confirmed by both the Korean Program Director and the Director of Nursing. The Director of Nursing further stated that the belt was used to prevent the resident from standing up, and there was no completed restraint assessment for this resident. Medical records indicated the resident had diagnoses including metabolic encephalopathy, unspecified dementia with psychotic disturbance, reduced mobility, and a lesion of the sciatic nerve. The resident's BIMS score was 4, indicating severe cognitive impairment. Documentation showed an order for the self-releasing belt to be applied when the resident was in the wheelchair, and the care plan noted the use of the belt due to risk for skin injury. However, nursing notes confirmed the resident was unable to self-release the belt, and the facility's policy defined physical restraints as devices that the individual cannot remove easily, which restricts freedom of movement.