Improper Use of Physical Restraint Without Physician Order or Assessment
Penalty
Summary
A deficiency was identified when a resident with acute respiratory failure, a history of cardiovascular accident, seizure disorder, anxiety disorder, and who was ventilator and gastrostomy tube dependent, was found with both hands inside pillowcases that were taped around their wrists. The resident was observed to be restless and agitated while on a mechanical ventilator. Facility policy requires that physical restraints only be used when medically necessary, with proper assessment, physician orders, and documentation, and that the least restrictive interventions be used. However, there was no evidence in the medical record of a physician's order or assessment for the use of limb restraints for this resident. The incident was discovered when an LPN entered the resident's room and observed the restraint. The LPN immediately notified the supervising RN, who removed the restraints. Interviews with staff revealed that the resident had previously exhibited agitated behavior and had attempted to remove their tracheostomy, but there was no documentation or order for the use of hand mittens or other restraints. The respiratory therapist responsible for applying the restraints reported that the resident had decannulated themselves multiple times during the night and, unable to obtain hand mittens, used pillowcases and tape as a restraint. The facility's investigative summary confirmed that the respiratory therapist applied the restraints without following protocol, and there was no prior use or order for hand mittens or limb restraints for this resident. The facility's restraint policy was not followed, as there was no assessment, physician order, or documentation supporting the use of restraints, and the intervention used was not the least restrictive option as required by policy.