Failure to Care Plan for Restraint Use After Resident Found with Wrists Tied
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive, person-centered care plan addressing the use of restraints for a resident with dementia, Alzheimer’s disease, muscle weakness, and gait and mobility abnormalities. The resident was admitted with significant cognitive impairment, as the physician history and physical documented that she did not have the capacity to understand and make decisions. A fall risk assessment showed a high fall risk score of 21, and the MDS indicated she rarely understood and was rarely understood, and required varying levels of staff assistance with ADLs including showering, dressing, eating, oral hygiene, toileting, footwear, and personal hygiene. Despite these conditions and her dependence on staff, there was no care plan in place addressing the use of restraints for this resident. On the night in question, the resident was described as restless and yelling intermittently. An LVN asked a CNA to check on the resident; the CNA later reported the resident was okay and that she always behaved that way. About 10 minutes later, the resident again yelled out, prompting the LVN to enter the room. The LVN observed the resident’s blanket on the floor, picked it up, and then saw that the resident’s wrists were tied together in front of her with what appeared to be a long scarf while she was in bed. The LVN untied the scarf and assessed the resident, noting no visible injury. Subsequent review of the care plan with the resident care manager revealed that there had been no prior care plan for the use of restraints, and the manager acknowledged that the scarf had been used as a restraint and should have been care planned. The facility’s change of condition policy required updating the care plan to reflect the resident’s current status after significant changes, but the report indicates the lack of a comprehensive care plan addressing restraint use at the time of the incident.
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