Failure to Assess, Document, and Obtain Consent for Use of Bilateral Hand Mittens as Restraints
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from physical restraints unless needed for medical treatment, in accordance with its own restraint policy. During an initial tour, a resident who was nonverbal and severely cognitively impaired (BIMS score of 0) was observed in bed wearing bilateral hand mittens. The resident’s history and physical documented that the resident lacked capacity to understand and make decisions. The facility’s policy defined physical restraints, listed hand mitts as a possible restraint, and required a pre-restraint assessment, identification of a specific medical symptom, attempts at less restrictive interventions, informed consent, and detailed physician orders and documentation when restraints are used. Medical record review showed a physician’s order for hand mittens to prevent the resident from pulling out medical devices, but the order did not include the required medical symptoms, frequency, duration, or monitoring parameters for the mittens. The record lacked any assessment to determine the existence of medical symptoms warranting restraint use and did not show that less restrictive measures were attempted before applying the mittens. There was no documentation that the resident’s responsible party had been informed of the potential risks and benefits of the mittens or that consent for their use had been obtained, despite the facility policy requiring such consent. Further review of the resident’s record showed no care plan addressing the use of bilateral hand mittens, including no interventions related to restraint reduction or underlying causes of the behavior. The facility also failed to document key elements required by its policy while the mittens were in use, such as the anticipated length of time the restraint would be used, who could apply it, when and how it should be applied, and monitoring of circulation, mobility, and skin. During interviews, an LVN confirmed the resident was wearing bilateral mittens due to episodes of pulling tracheostomy tubing and verified the absence of required assessments, documentation of least restrictive measures, responsible party notification, consent, and care planning. The DON and Administrator were later informed of and acknowledged these findings.
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