Failure to Assess, Document, and Care Plan for Use of Physical Restraint Mitt
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical diagnoses, including Parkinson's disease, stroke history, COPD, dysphagia, hemiplegia, and schizophrenia, was observed wearing a restraint mitt on the left hand. The facility's policy requires a documented medical symptom, assessment, physician order, and care plan interventions before the use of any physical restraint. However, the resident's medical record lacked any restraint assessment, physician order, or care plan documentation related to the restraint mitt. Staff interviews confirmed the mitt was used to prevent the resident from pulling on a feeding tube, but none could identify who applied it or provide evidence of required documentation or assessment. The resident's care plan did not address the use of the restraint mitt, and there was no documentation of less restrictive alternatives being attempted or ongoing re-evaluation of the restraint's necessity. The Director of Nursing and Nurse Practitioner both confirmed the absence of an order or care plan for the mitt, and the mitt's use was not mentioned in the resident's recent hospital discharge summary. The facility failed to follow its own policy and federal requirements regarding the use of physical restraints, resulting in the imposition of a restraint without proper assessment, documentation, or care planning.