Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to comprehensively assess the use of a low bed as a potential physical restraint for a resident with severe cognitive impairment, Parkinson's disease, hypertension, arthritis, and a history of falls. The resident required extensive assistance with activities of daily living, including bed mobility, transfers, and toileting, and used a wheelchair for mobility. Despite the resident's ability to stand independently, staff placed the bed in the lowest position as an intervention following a fall, with the intention of preventing further falls. However, there was no documentation of a restraint assessment being completed prior to implementing this intervention, and the resident's care plan and assessments did not identify the low bed as a restraint. Observations and staff interviews revealed that the low bed made it difficult for the resident to stand up independently, and staff were unsure whether the low bed constituted a restraint. The facility's policy defined a physical restraint as any device that restricts freedom of movement and cannot be easily removed by the resident. Despite this, the low bed was not evaluated as a potential restraint, and the required assessment was not performed before its use. The director of nursing confirmed that a restraint assessment should have been completed but was not done in this case.