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

A deficiency occurred when a resident was observed using a seatbelt in a motorized wheelchair without a physician's order or signed consent documented in the electronic health record (EHR). The seatbelt, which functioned as a physical restraint to prevent falls, was applied without the required assessment or documentation. Staff interviews revealed a lack of awareness that a physician's order and consent were necessary for the use of a seatbelt as a restraint, and that a physical therapy assessment had not been completed for this intervention. The resident involved had multiple complex medical diagnoses, including bipolar I disorder, intellectual disability, developmental delay, PTSD, hypertension, insomnia, prediabetes, traumatic brain injury, aggressive behavior, and a history of a sacral pressure ulcer. The resident was dependent for mobility, had upper and lower extremity deficits, and was unable to complete a mental status interview. The facility's own policy required a signed order and assessment for any restraint use, which was not followed in this case.