Failure to Obtain Required Evaluation and Orders for Physical Restraints
Penalty
Summary
The facility failed to obtain a Safety Device Evaluation and Consent and/or physician's order for two residents who were using physical restraints, as required by facility policy. For one resident with severe cognitive impairment, the bed was observed in a low position multiple times, but there was no documentation of a Safety Device Evaluation, physician's order, or care plan intervention related to this practice. Staff confirmed that such documentation and orders were required but not present in the resident's electronic health record or care plan. For another resident with moderate cognitive impairment, the bed was observed placed against the wall on several occasions, but again, there was no Safety Device Evaluation, physician's order, or care plan intervention documented. Staff interviews revealed that the bed was moved against the wall at the resident's request to prevent rolling out, but staff were unaware of the need for evaluation and documentation. The Director of Nursing confirmed that it was expected for evaluations, consents, and physician's orders to be in place for beds in low positions or against the wall, but these were not completed for the residents involved.