F0604

D

Use of Geriatric Chair as Undocumented Physical Restraint

Chrisman, Illinois Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

Surveyors identified that a cognitively intact resident with multiple diagnoses, including osteomyelitis, sacral pressure ulcers, neoplasm of the spinal cord, type II diabetes, polyneuropathy, unsteady gait, and neurofibromatosis, was being kept in a geriatric chair that did not allow self-propulsion. On observation, the resident was seated in this chair in her room while her personal wheelchair, labeled with her name, was placed across the room. The resident stated she wanted to sit in her own wheelchair, expressed that she could not move around her room in the geriatric chair, and reported she could not independently access personal items such as her hairbrush or soda. She further stated that the chair made her back and existing Stage IV pressure ulcers hurt and that staff told her the chair was used because she attempted to transfer from bed to chair and had experienced falls, leading her to feel restricted.

The DON stated that the geriatric chair was used for the resident’s safety and positioning and confirmed that the chair did not allow the resident to self-propel. The DON also acknowledged that no restraint assessment had been completed because staff did not consider the geriatric chair to be a restraint, and that the use of the geriatric chair was not addressed in the resident’s care plan. The facility’s own physical restraint policy defines physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement, and states that restraints are not to be used for punishment or staff convenience and require periodic assessment to reduce or eliminate their use. Despite this policy, the geriatric chair, which limited the resident’s freedom of movement and was not easily removable by the resident, was used without restraint assessment or care plan inclusion.