Failure to Prevent Unnecessary Use of Physical Restraints
Summary
The facility failed to ensure that a resident with dementia and combative behavior was free from physical restraints, which were used for discipline or convenience. On one occasion, a Licensed Vocational Nurse (LVN) restrained the resident by crossing their arms across the chest and above the head, dragging them from their room to the Nursing Station. This action was taken when the resident exhibited mood swings, anxiety, and agitation, leading to physical injury, including redness and bruising on the resident's hand, and verbalized pain in both hands and shoulders. The facility did not implement the resident's care plan interventions for dementia and communication problems, which included establishing rapport, making eye contact, and using appropriate words and gestures. The Interdisciplinary Team (IDT) failed to develop a comprehensive care plan to address the resident's new behaviors, such as combativeness, punching, scratching, and kicking, which were observed on multiple occasions. The care plan was not updated to address the root cause of the resident's behavior symptoms, nor were specific interventions developed to manage the resident's agitation and combativeness. The facility's policy on Physical Restraint Management was not followed, as the LVN used physical restraints to prevent being hit, kicked, and spit on by the resident. This resulted in the resident's freedom of movement being restricted, causing physical and psychosocial harm. The facility's failure to address the resident's behavioral issues and implement appropriate care plan interventions led to the unnecessary use of physical restraints, placing the resident and others at risk for further harm.
Removal Plan
- The facility interviewed 30 interviewable residents and screened for any incidents of being physically restrained during care by the Social Services Designee and 12 non-interviewable residents received body check to determine any unexplained bruising or redness by licensed nurses and the DON.
- The facility started Training and Education headed by the Nurse Consultant Director of Staff Education and the DON, regarding abuse and physical restraints. The training on Managing Behavior and Care plan will be completed.
- The facility started ln-service training for staff nurses regarding updating comprehensive care plans for residents that exhibit combative behaviors to be completed and to include on the care plan not to use any type of restraints.
- The facility started an In-service training for staff and nurses on managing residents that exhibit combative behaviors. Staff from nursing department (Registered Nurse, LVN, Certified Nurse Assistants, Restorative Nurse Assistants) Dietary Department, Housekeeping, Maintenance and Department Managers (Social Service, Medical Records staff, Rehabilitation Department, Minimum Data Set, DON, DSD, IPN, Business Office Manager), have been trained and will continue training until all staff have attended.
- The facility conducted an In-service training for staff (RN, LVN, CNA, RNA, Housekeeping, Dietary Department, Maintenance and Department Managers) on what constitutes a physical restraint and its definition.
- The nurse consultant conducted an In-service to all RNs, LVNs, CNAs, and RNAs, Housekeeping, Maintenance staff, Dietary staff, and Department Managers regarding Behavior Management, Abuse and Physical Restraints.
- The SSD, DON and Activity Director will conduct interviews of alert residents to determine if they have been physically restrained during care at least daily for the next 3 days and weekly for two weeks and monthly thereafter.
- CNAs will continue to conduct body checks for all residents to identify any unexplained redness or bruising during showers and will be reported to the Charge nurse/Treatment nurse and/or to DON for further intervention and reporting.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with severe cognitive impairment and BPH had an order for repeated UA with C&S. When the resident could not void into a urinal and verbally resisted catheterization by saying "Don’t do that" and crossing his legs, an LPN called two CNAs into the room. The CNAs held the resident’s arms and legs while the LPN performed an in-and-out catheterization to obtain the urine specimen. During the procedure, bright blood was observed in the catheter tubing and the procedure was stopped. Subsequent nursing notes documented the resident’s anxiety, later pain with urination, hematuria, and blood clots, leading to NP notification and hospital transfer. The facility’s investigation, including staff statements and a visitor account, concluded that the resident had been physically restrained against his will during the procedure, and the allegation of abuse by restraint was substantiated.
Resident Restrained for Urine Catheterization Resulting in Harm
Penalty
Summary
The deficiency involves facility staff physically restraining a cognitively impaired resident during an in-and-out catheterization to obtain a urine specimen, despite the resident’s resistance and inability to consent. The resident had benign prostatic hyperplasia and was documented as severely cognitively impaired on the admission MDS, with a BIMS score of 4/15 and always incontinent in the urinary continence section. A physician’s order directed that a urinalysis with culture and sensitivity be obtained every shift for three days. On the evening in question, the LPN attempted to obtain the ordered urine specimen via straight catheterization after the resident was unable to void into a urinal. According to the facility’s own investigation and staff statements, when the LPN entered the room to insert the catheter, the resident verbally resisted by saying “Don’t do that” and crossed his legs. The LPN then called for assistance from two CNAs. The visitor present was asked to leave the room, and while in the hallway, the visitor heard the resident yelling but could not make out the words. CNA statements and the facility’s synopsis of events documented that the two CNAs held the resident’s arms and legs while the LPN proceeded with the catheter insertion in order to obtain the urine specimen. The facility’s findings concluded that the CNAs did hold the resident’s extremities during the procedure and that the resident was restrained against his will. During the catheterization, bright blood was noted in the urine sample, and the LPN stopped the procedure when blood was seen entering the catheter tubing. Nursing notes documented that the resident appeared anxious but stable immediately afterward. Later that night and early the following morning, the resident experienced discomfort and pain with urination, with hematuria and blood clots noted in the brief, leading to notification of the on-call NP and transfer to the hospital. The facility’s grievance report and investigation summary documented that the catheter was used for a urine sample against the resident’s will, resulting in bleeding in the groin area and hospitalization, and that the allegation of abuse by restraint was substantiated based on staff interviews and the definition of abuse in the facility’s policy as willful infliction of injury or unreasonable confinement with resulting physical harm, pain, or mental anguish.
Removal Plan
- Staff members involved were placed on paid administrative leave pending investigation and subsequently terminated and reported to their respective licensing agencies.
- Immediate skin assessment completed on Resident 42; no skin impairment or changes noted.
- Resident 42 was evaluated by the facility social worker for psychosocial distress related to the incident; no distress was reported or observed.
- Residents with orders for straight catheterization were identified as potentially affected.
- Immediate skin checks were completed for all residents.
- Interviews were conducted with residents and no care issues or restraint issues were identified.
- CNAs, LPNs, RNs, Dietary, Social Services, Housekeeping, Therapy, Maintenance, Activities and MDS Coordinator were in serviced and educated on restraint policies and procedures and who the coordinator to whom concerns should be reported.
- Staff were educated on a resident's right to refuse or decline care and procedures and how nursing staff are to respond when a resident refuses care or treatment.
- Staff attending the training were educated to offer alternatives if possible and provide education on the needed treatment.
- New hire and annual training will be assigned and monitored for completion.
- Training regarding restraint use will be given for all new hires during orientation and annually for all employees.
- Resident grievances will be monitored continually for concerns regarding restraint use.
- The DON or designee will audit skin checks weekly for 50% of resident census to monitor for concerns.
- The Administrator or designee will conduct resident interviews to monitor satisfaction with care and monitor for reports of restraint use.
- Compliance and audit reports will be monitored through the facility QAPI program.
- The Administrator is responsible for ongoing compliance.
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