Unauthorized Use of Arm Strap Restraint Without Assessment or Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from an unauthorized physical restraint. A resident with dementia, severe cognitive impairment (BIMS score 3/15), hemiplegia/hemiparesis following a stroke, and a history of repeat falls was readmitted with care plans addressing fall risk and the need for assistance with transfers and proper use of devices. The facility’s restraint policy defines physical restraints as any device attached to the body that the resident cannot easily remove and requires a specific physician order, including type, frequency, duration, and monitoring. Record review showed no documentation of a physician’s order, restraint assessment, identified medical symptoms being treated, or alternative interventions attempted for this resident, and the MDS assessment did not indicate any restraint use. During surveyor observations, the resident was seen in a wheelchair with an elevated-arm lateral body support, and the right arm was secured to the device with a black Velcro strap that restricted arm movement while the resident attempted to feed themself; the strap remained in place throughout the meal. The primary NA reported that the black strap was present every day and considered it part of the chair. The DNS stated she was unaware that an arm strap was in use, and the Director of Rehabilitation acknowledged the strap was in place but was unsure if it should be and stated he had never seen one like it with that device. When asked, the resident did not remove the strap before the DNS removed it. The NP confirmed that the resident should not have a strap on the right arm because it would be considered a restraint. The DNS was unable to provide evidence that the facility had assessed the need for a physical restraint, evaluated least restrictive alternatives, determined duration of use, or conducted required re-evaluations, as required by regulation and facility policy.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.