Failure to Document and Monitor Physical Restraint Use as Ordered
Penalty
Summary
The facility failed to ensure that services provided to a resident met professional standards of quality, specifically regarding the use and monitoring of physical restraints. For one resident with multiple complex medical diagnoses, including acute respiratory failure, seizure disorder, and ventilator dependence, bilateral hand mittens were ordered by a physician to prevent the resident from pulling out their tracheostomy tube. The physician's order required that the mittens be released every two hours for range of motion and skin checks. However, there was no documented evidence in the medical record that this was done as ordered. The facility's own policy required monitoring and documentation of restraint use, but this was not reflected in the resident's records. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for monitoring and documenting the use of hand mittens. Certified Nursing Assistants believed nurses were responsible for applying and monitoring the mittens, while nurses indicated that documentation should occur on the Treatment Administration Record. Multiple staff members, including a Registered Nurse and the Director of Nursing, confirmed that there was no documentation of the required monitoring and release of the mittens for the resident. The deficiency was identified through observations, record reviews, and staff interviews.