Failure to Follow Care Plan for Hand Mitten Restraint Use
Penalty
Summary
Surveyors identified that the facility did not follow the care plan and policy for restraint use for one resident who had a physician’s order for a left hand mitten due to persistent pulling out of a gastrostomy tube (GT). The facility’s Physical Restraints policy, revised 1/2017, required that when restraints are used, the resident must be provided with motion and exercise for at least 10 minutes during each two-hour period. The resident’s care plan for use of the left hand mitten, initiated on 3/10/25 and revised on 11/9/25, included an intervention to apply the left hand mitten to prevent pulling out the tube and to release it every two hours for 15 minutes for circulation and comfort. Review of the resident’s medical record, including the MAR for March 2025, showed that the left hand mitten placement was monitored every shift from 3/10 to 3/31/25, but there was no documented evidence that the mitten was released every two hours as required by the care plan. During an interview and concurrent record review, an RN stated that the facility protocol for hand mitten restraints was to remove them every two hours and check circulation and skin condition, but confirmed that there was no physician order to monitor circulation and skin condition every two hours and no documentation that the mitten was released every two hours for circulation and comfort. The Administrator was informed of and acknowledged these findings.
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