Sample Care Area Assessment (CAA) for Physical Restraints

Resident Information:

• Name: George Smith
• ID: 874563
• Date of Assessment: YYYY-MM-DD
• Room Number: 310

Assessment Team:

• Primary Nurse: Diana Ross
• MDS Coordinator: Eric Johnson
• Occupational Therapist (OT): Laura Adams
• Physical Therapist (PT): Michael Brown
• Psychologist: Dr. Anita Gomez

Care Area Assessed:      

• Specify the care area: Physical Restraints

Step 1: Triggered Care Areas

• Triggered by the temporary use of wrist restraints following several falls from bed and attempts to leave the facility unsupervised. Concerns have been raised regarding the ethical implications, resident dignity, and regulatory compliance.

Step 2: Review of MDS 3.0 Findings

• George has a diagnosis of mild cognitive impairment and has recently exhibited increased confusion and agitation, leading to safety concerns that resulted in the use of physical restraints.

Step 3: Detailed Assessment

• Clinical findings: Evidence of increased agitation and confusion, particularly at night, contributing to unsafe attempts to ambulate independently.
• Review of medical records: Documentation of recent falls, the decision-making process for the use of restraints, and ongoing monitoring for adverse effects.
• Consultations with interdisciplinary team members: Discussions on alternative interventions to ensure safety without compromising George's autonomy or well-being.
• Resident and family interviews: Expressions of concern regarding the use of restraints and a strong preference for alternative measures.

Step 4: Problem Identification

• Risks associated with the continued use of physical restraints include potential physical and psychological harm, decreased quality of life, and non-compliance with regulatory guidelines advocating for restraint-free care environments.

Step 5: Care Planning

• Goal: To eliminate the use of physical restraints through the implementation of alternative strategies that address the underlying causes of George's behavior while ensuring his safety and compliance with care standards.
• Interventions:

• • Assess and optimize the environment to reduce triggers of agitation and confusion, potentially using visual cues and secure wandering paths.
  • Implement a comprehensive behavioral intervention plan, developed in collaboration with the psychologist, to address agitation and confusion.
  • Increase supervision during high-risk times, utilizing additional staff or volunteer support, to prevent falls and wandering.
  • Review and adjust medication as needed to manage symptoms of cognitive impairment without exacerbating confusion or agitation.
  • Engage OT and PT to assess the need for assistive devices or environmental modifications to promote safe mobility.

• Responsible Staff: OT, PT, Nursing Staff, Psychologist
• Timelines: Immediate reassessment of restraint necessity, with the introduction of alternative interventions and regular monitoring for effectiveness and resident safety.

Step 6: Interdisciplinary Team Review

• The team collaborates on George's care plan, prioritizing the exploration of all possible alternatives to physical restraints to enhance his autonomy and well-being.

Step 7: Resident and Family Engagement

• Engaging George and his family in the care planning process ensures that they are informed, supportive, and involved in the decision-making process regarding his care and safety interventions.

Step 8: Monitoring and Reassessment

• Short-Term: Daily monitoring of George's response to alternative interventions and adjustments based on his needs and safety requirements.
• Long-Term: Ongoing evaluation of the effectiveness of the restraint-free approach, with periodic reassessment of George's overall care plan to ensure it continues to meet his needs and regulatory standards.

Documentation and Signatures:

• Signature of MDS Coordinator: Eric Johnson, Date: YYYY-MM-DD
• Signature of Primary Nurse: Diana Ross, Date: YYYY-MM-DD
• Signatures of other interdisciplinary team members involved.

IDT Meeting Follow-Up:

• Scheduled Date: YYYY-MM-DD to review progress in reducing the use of physical restraints, address any challenges encountered, and refine the care plan to maintain a safe, respectful, and dignified environment for George.