Failure to Perform Ongoing Assessment for Physical Restraint Use
Penalty
Summary
Surveyors identified a deficiency related to the use and assessment of a physical restraint for one resident. The resident was observed seated in a wheelchair in the hallway by the nurse’s station wearing a waist (lap) restraint attached to the wheelchair. Documentation showed a Physical Restraints Informed Consent dated 08/22/2024 indicating the lap restraint was used due to dementia, non-compliance with transfer status, impulsive behavior, and poor trunk control. A restraint assessment from the same date documented that the device prevented the resident from standing, transferring, or walking, met the definition of a restraint, and that the resident was unable to remove it independently, with staff responsible for removing it during ADLs. The Medication Administration Record for 08/2025 showed ongoing use of the waist restraint with instructions to check every two hours for skin integrity and circulation, marked as completed on all shifts from August 1 through August 11, 2025. Despite the ongoing use of the restraint, staff interviews and records revealed a lack of ongoing restraint assessments. The Restorative Nurse stated that restraint assessments should be completed annually and quarterly and that if the restraint is used for trunk support, the restorative nurse performs the assessment; however, the only restraint assessment available for this resident was dated 08/22/2024. The Falls/Psychotropic Nurse reported that the resident was a fall risk and that the restraint was used due to poor trunk support, but acknowledged having no restraint assessment or restraint reduction assessment for the resident. Additionally, the resident’s MDS dated 07/2025 indicated that physical restraints were not used, which conflicted with the observed and documented use of the lap restraint. The facility’s restraint policy, revised 07/03/25, stated that the use of the restraining device may be assessed and reduced at least quarterly, but there was no evidence of such ongoing assessments for this resident.
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