Failure to Obtain Physician Order and Consent for Restraint Devices
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary restraints by not obtaining a physician's order or informed consent for the use of a lap buddy and pressure pad alarm on the resident's wheelchair. Observations and interviews confirmed that the resident was using these devices, but a review of the medical record showed no documentation of a physician's order, informed consent, or a care plan addressing their use. The facility's policies require a physician's order, informed consent, and a resident-centered care plan for any physical restraint, including devices such as lap buddies and alarms that the resident cannot remove easily. The resident in question had severe cognitive impairment, as indicated by a BIMS score of 00 and documentation that the resident lacked capacity to make decisions. Staff interviews revealed that the devices were used to alert staff if the resident attempted to get up unassisted, due to episodes of leaning forward. Despite this, there was no evidence that the required assessments, orders, or consents were completed prior to the application of these devices. Further interviews with nursing staff and facility administration confirmed the absence of a physician's order, informed consent, and a care plan for the use of the lap buddy and pad alarm. The facility's own policies, as reviewed, clearly outline the steps required before applying such devices, including assessment by the interdisciplinary team and ongoing documentation, none of which were present in this case.