Improper Use of Physical Restraints
Penalty
Summary
Buffalo Valley Lutheran Village was found to be non-compliant with federal and state regulations regarding the use of physical restraints. The facility failed to ensure that a physical restraint was used for the treatment of medical symptoms for one resident. The incident involved a nurse who tied a resident to her wheelchair with a shawl, despite the absence of a physician's order or a plan of care authorizing such a restraint. The resident had a history of noncompliance with transfer status and behaviors of frequently placing herself on the floor. The facility's policies on abuse prevention and restraint use were not adhered to, as evidenced by the actions of Employee 1, who tied the resident to her wheelchair multiple times. Despite being informed by other staff members that the use of the shawl as a restraint was inappropriate, Employee 1 continued to use it. The supervisory staff, including Employee 2, failed to immediately suspend Employee 1 after the initial report of inappropriate restraint use, allowing the nurse to continue working and potentially restrain other residents. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed that there was no evidence of counseling for Employee 2 regarding the failure to suspend Employee 1. Additionally, there was no evidence of staff education following the incident to reinforce the facility's policies on restraint use and resident protection during abuse investigations. This lack of immediate action and education contributed to the facility's non-compliance with the regulations.
Plan Of Correction
Please accept the following Plan of Correction as the facility's credible allegation of compliance with F604. This Plan of Correction is being submitted in response to the regulatory requirement and should not be considered an admission of guilt or liability by the facility. Resident #1 assessed by RN supervisor on 2/12/2025 after removal of shawl. No injuries or change in demeanor/level of alertness noted. Employee 1 was suspended pending investigation on 2/11/2025 and was terminated from employment on 2/13/2025. Residents residing in the facility have the potential to be affected. Resident #1 and all residents will be free from restraints. All residents residing in facility on 2/28/2025 will be audited for restraints. Facility staff educated on policy and procedure that residents should be free from restraints. Education included: - Reporting of improper use of restraint - Proper consent, order, and managing of restraint if a restraint is needed - RN supervisors/managers were re-educated on steps to take when abuse is witnessed or reported to them. - New Hire orientation education reviewed and revised to include education that residents will be free from restraint. The Director of Nursing or designee will audit 20 random residents weekly x 4 weeks, then 10 residents monthly x 2 months for improper restraint use. Results will be reported to the Executive Director. Any variance noted will be corrected immediately. The Executive Director or designee will report results of the audits monthly in the Quality Improvement meeting. Trends and analysis will be evaluated. If there are any negative trends or analysis the community will adjust the plan to assure that residents remain free from restraints.