Improper Use of Restraints on Resident
Penalty
Summary
Jersey Shore Skilled Nursing and Rehabilitation Center was found to be non-compliant with federal and state regulations regarding the use of physical restraints. The facility failed to ensure that a resident was free from abuse when a sheet was used as a restraint on two separate occasions without a medical or emergent need. On January 8, 2025, a licensed practical nurse (LPN) used a sheet to tie a resident to a chair because the resident would not stay seated. This action was not documented as medically necessary, and no physician's order or consent was obtained. Another LPN observed the restraint but did not report it to a supervisor. On January 11, 2025, a similar incident occurred when a nurse aide and an LPN restrained the same resident using a sheet, again without a documented medical reason or physician's order. The resident was observed by other staff and residents to be distressed during the application of the restraint. Statements from staff indicated that this practice had been occurring previously, suggesting a pattern of inappropriate restraint use. The facility's policies on abuse prohibition and restraint use were not followed, as evidenced by the lack of documentation and failure to use the least restrictive alternatives. Additionally, the therapy department had not received updated training on restraint and abuse prevention following the incidents. The facility's administrator acknowledged these findings and confirmed the lack of immediate reporting and training updates.
Plan Of Correction
The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction. 1. Resident #1 was evaluated by the interdisciplinary team for injury and safety needs, as well as the need for any restraint or alternative interventions. Plan of care updated related to needs, with provider and family involvement. 2. All residents have the potential to be affected by this alleged deficient practice. A facility wide abuse audit and restraint audit was completed to ensure no further concerns were found with any other resident or resident representative. 3. All facility staff received abuse and restraint training with emphasis on notifying the provider when a resident has a change in condition that may require a restraint, as well as immediate notification to the abuse coordinator with alleged abuse. Interdisciplinary team will review all alleged abuse/restraint allegations daily to ensure abuse/restraint process is being followed if incidents occur. 4. Administrator/designee will complete an abuse/restraint post test for 10 random employees weekly x 4 weekly, then 5 random employees x 2 months or until substantial compliance is met to ensure training is retained. Administrator/designee will complete abuse/restraint questionnaires with 10 random residents/resident representatives x 4 weeks, then 5 x 2 months or until substantial compliance is met, to ensure all concerns are addressed per process. Administrator and/or designee will bring results of audits to QAPI committee for further recommendations based on tracking and trending presented monthly for the next 3 months or until ongoing compliance is achieved. 5. Date of compliance: 2/25/2025