Unassessed Wheelchair Seat Belt Used as Physical Restraint
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from physical restraints when a seat belt on a motorized wheelchair was not identified or managed as a restraint. The resident had diagnoses including traumatic subarachnoid hemorrhage with loss of consciousness, lack of coordination, abnormal posture, right-sided hemiplegia, history of traumatic brain injury, aphasia following cerebral infarction, and contractures of the right elbow, wrist, and hand. The quarterly MDS documented the resident as cognitively intact with bilateral upper extremity range-of-motion limitations, use of a motorized wheelchair, and no restraints. The comprehensive care plan identified an ADL self-care performance deficit related to right hemiparesis and noted use of a power chair with a back cushion for safety and independence, but it did not identify any problem, intervention, or order related to a seat belt, despite the resident being observed repeatedly with a seat belt in use. Surveyors observed the resident on multiple occasions seated in the motorized wheelchair with a seat belt on, including observations where the buckle was off to the right side of the lap and the resident had a visible right arm contracture. When asked, the resident stated they could release the seat belt and later reported that the seat belt was not comfortable, indicating discomfort by leaning forward and touching the lower left back. CNAs reported that residents with electric wheelchairs had seat belts, that they placed the seat belt on this resident when transferring them into the wheelchair in the morning, and that it remained on all day until bedtime or toileting. CNAs also stated they had been trained during orientation and by rehab staff regarding seat belt use and believed some residents could remove the belts themselves. Interviews with nursing, MDS, and rehab leadership revealed inconsistent understanding and lack of assessment or documentation regarding the seat belt. The RN/Unit Manager confirmed there was no order or care plan for the resident’s seat belt use. The MDS coordinator stated seat belts were not captured on the MDS because rehab was believed to assess them and determine residents’ ability to remove them, and acknowledged these interventions should be care planned. The Director of Rehab stated the department did not use or assess seat belts, was unaware CNAs were applying them, and later provided a prior physical therapy plan of treatment documenting that the resident was able to unbuckle the seat belt upon command but needed assistance with buckling, and that the resident was at risk for falls and injury during power chair mobility. The last occupational therapy wheelchair assessment contained no documentation or assessment of the seat belt. The facility’s restraint policy defined physical restraints as devices that the individual cannot remove easily which restrict freedom of movement or access to the body, and required EMR documentation to support assessment and use of restraints, which was not present for this resident’s ongoing seat belt use.
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