F0604

D

Improper Use of Gait Belt as Physical Restraint in Wheelchair

Americus, Georgia Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from physical restraints, as required by its policy titled "Restraints/Bed Rails" and regulatory standards. The facility’s policy states that residents have the right to be free from any physical restraints imposed for discipline or staff convenience and not required to treat medical symptoms. The resident involved, identified as R6, had multiple diagnoses including type 2 diabetes mellitus, mood disorder, hypertension, chronic obstructive pulmonary disease, and benign prostatic hyperplasia. A quarterly MDS with an ARD of 11/19/2025 documented a BIMS score of 1, indicating severe cognitive impairment. The care plan noted cognitive decline and emphasized respecting the resident’s right to make decisions.

Progress notes from 11/10/2025 through 1/11/2026 documented a situation in which staff used a gait belt to restrain R6 to his wheelchair. During an interview, an LPN reported receiving a call from a CNA who informed her that the resident was tied to a wheelchair with a gait belt. Another CNA described that the resident had been getting out of bed despite bedside mats and was placed in a wheelchair; when preparing to use a Hoyer lift to transfer the resident to bed, the CNA observed a gait belt wrapped around the resident’s upper body and the outer back of the wheelchair, effectively restraining the resident. The CNA immediately removed the gait belt and transferred the resident to bed. The report notes that the responsible party was notified and that the resident did not sustain injuries. The DON later stated that a CNA was terminated for substantiated abuse, and the Administrator stated that her expectation is that no residents be restrained.