Failure to Ensure Proper Assessment and Training Before Use of Wheelchair Restraint
Penalty
Summary
The facility failed to ensure that a resident was not restrained in a wheelchair without adequate training, assessments, and physician orders. The resident, who had diagnoses including dementia, Down syndrome, severe cognitive impairment, and a history of falls, was provided with a new custom-fitted wheelchair equipped with a seatbelt and harness. The harness and seatbelt were intended to aid in positioning and prevent falls, but their use was not properly assessed or ordered prior to implementation. Staff began using the harness and seatbelt immediately after the wheelchair's arrival, despite not having received comprehensive training or clear guidance from therapy or the interdisciplinary team. There was confusion among staff regarding when and how the harness should be used, with some staff applying it routinely and others only in specific situations such as during meals or when the resident was leaning significantly. The resident's family expressed conflicting wishes about the use of the harness, at times requesting its use and at other times objecting to it, particularly after observing a red mark on the resident's neck. Documentation and interviews revealed that staff were not uniformly educated on the proper application of the harness, and therapy staff were not present for the initial fitting or evaluation of the wheelchair. Orders and assessments for the use of the harness and seatbelt were completed only after their use had already begun. The lack of a coordinated assessment and training process led to inconsistent and potentially unsafe application of the harness, resulting in physical signs of harm such as a red mark on the resident's neck. Staff statements indicated uncertainty about whether the harness constituted a restraint and how it should be used, and there was no clear documentation or communication regarding the intended protocol. The facility's own policy required an interdisciplinary assessment and consideration of less restrictive alternatives before implementing restraints, which was not followed in this case.