Resident Restrained by CNA During Care
Summary
The facility failed to protect a resident from being physically restrained by a Certified Nursing Assistant (CNA). During incontinence care, the CNA grabbed both of the resident's hands and held them crossed against the resident's upper chest. This incident was reported by the Social Services Director, who stated that the resident felt distressed and abused by the CNA's actions. The Director of Nursing confirmed that the CNA admitted to restraining the resident, claiming it was necessary to prevent being hit. The resident involved in the incident was admitted with multiple medical conditions, including respiratory failure, end-stage renal disease, and bilateral below-knee amputations. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status. The resident's care plan noted a self-care deficit related to activities of daily living and impaired mobility, which required assistance from staff. Interviews with the resident and staff revealed that the CNA entered the resident's room to provide care when the assigned CNA was unavailable. The resident reported that the CNA was rough and aggressive, causing fear of potential harm to the dialysis catheter. The CNA's actions were not in line with the facility's policy on maintaining a restraint-free environment, which prohibits the use of physical restraints unless medically necessary.
Removal Plan
- LPN1 informed the Unit Manager and the Director of Nursing of the allegation.
- LPN1 remained with the resident pending the arrival of the DON to start the investigation.
- The DON contacted CNA1 via phone and suspended him. The DON requested that CNA1 provide a written statement regarding his interactions with R1. The DON interviewed CNA1 in which he admitted that he restrained the resident.
- The DON provided notification to the South Carolina Department of Public Health of the allegation of abuse.
- The DON interviewed resident (R1) as a part of the investigation. She completed a body audit that was negative for marks or bruises. Resident (R1) disclosed that he was lying on his back with his legs bent. He demonstrated and it was observed that due to amputations his legs point up into the air. Resident #1 states that when CNA1 entered the room, CNA1 hit his legs and told him to put them down if he wanted to be changed. The resident did not disclose pain or injury from the open-handed contact but it made him mad and then he took a swing at CNA1. The resident then demonstrated how CNA1 crossed the resident's arms on his upper chest and held his arms.
- The DON notified the local police authorities. Officers responded and statements were taken and a report was filed.
- The DON contacted the family and left a message. The family returned the call and spoke with LPN1 regarding the allegations.
- LPN1 notified the Attending Physician of the allegation of abuse.
- The Social Service Director began to monitor the resident (R1) for residual and latent effects. She reports no latent effects and that the resident (R1) is glad that CNA1 no longer works there.
- The Social Services Director interviewed other residents able to be interviewed and no pattern was noted. No residents reported abuse or being restrained.
- The Staff Development Coordinator, DON and or Unit Manager/Coordinator began providing education to staff regarding restraints to include holding a resident's hands down. Education will be provided upon hire, annually and as needed.
- All education will be completed by Staff. Staff will not be allowed to work without completing the training.
- The Restraint Policy was reviewed by the DON, the Administrator and the Corporate Nurse Consultant. No Policy Revision needed at this time.
- The SDC will audit new hire Orientation Packets Monthly x 6 months and then quarterly to ensure that employees were provided training on restraints. The SDC will track and trend and report the results of the audits monthly x 6 months and then quarterly.
- Annually, the SDC, DON, or Designee will provide education to staff regarding Restraints. Annually, the SDC will audit all employee training records to ensure that all staff have received annual training. The SDC will track and trend her annual education audit and report to QAPI at least annually.
- An Ad Hoc QAPI Committee meeting was held with the Medical Director attending via phone. The plan of actions taken were reviewed and it was determined that the appropriate preventative actions had been taken. The Committee approved the addition of restraints as a focus to the new hire process and annual education.
- The Committee will monitor the results of the new hire and the annual training audits and make recommendations and modifications as needed to ensure continued compliance.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia, anxiety, depression, and diabetes was kept on a wander guard that restricted access to the outdoors, but the facility did not document the required reassessment of continued need. The resident stated she disliked wearing the device and wanted it removed because it prevented her from enjoying the outdoors, while staff and the DON acknowledged the device should have been reviewed quarterly and could not find documentation of a reassessment.
A resident with dementia and moderate cognitive impairment was found with a blanket tied to the bed frame across the chest, despite no restraint order, assessment, or care plan in the record. A CNA admitted she tied the blanket to keep the resident from getting up and potentially falling, and staff later described the blanket as tightly secured and functioning as a restraint. The LPN and DON both acknowledged that tying the blanket to the bed was not appropriate and constituted a restraint.
Seatbelt Used Without Required Restraint Assessment or Consent: A resident with Parkinson’s disease and post-surgical diagnoses was observed sitting in a power chair with a seatbelt on, but the record lacked documentation of a pre-restraint assessment or consent from the resident or representative before the seatbelt was used as a potential restraint. The ADON stated the resident should have been assessed and consent obtained, but could not find documentation that this occurred.
A resident with a PEG tube had an abdominal binder in place to prevent pulling out the tube, and the care plan directed that it be worn loosely and checked every shift. The record showed the binder was being used as a restraint, but no physician order was found for its use until much later, and the DON confirmed the order had not existed when the restraint was initiated.
Improper Physical Restraint Used During Respiratory Treatment: An RN secured a resident’s left hand to the side rail with a pillowcase while attempting to administer a nebulizer treatment after the resident became combative and removed the mask. The resident had dementia, severe cognitive impairment, respiratory failure, and functional quadriplegia, and the restraint was later observed by the hospice nurse and confirmed in the facility’s event investigation.
A resident with moderate cognitive impairment and a care plan addressing refusals of care was forcibly held down by an RN and CNA after refusing incontinent care multiple times. During the interaction, the resident became physically aggressive, but staff continued the care, with witness statements describing the RN directing that the resident had to be changed. The resident later reported being held down, having arms grabbed, clothing ripped off, and being washed with a cold rag; bruising, wrist redness, hand discoloration, soreness, and emotional distress were documented.
Failure to Reassess Continued Need for Wander Guard
Penalty
Summary
The facility failed to monitor and reevaluate the continued need for a wander guard used to restrict a resident from accessing the outdoors for 1 of 1 resident reviewed for restraints. The resident had moderate cognition, was independent with activities of daily living, and had diagnoses including dementia, anxiety, depression, and diabetes. The resident’s quarterly MDS identified daily use of a wander/elopement alarm, and the restraint/adaptive equipment assessment noted use of antidepressants, antipsychotics, anxiolytics, and narcotics, along with a recent decline in condition, but did not specify the decline. The assessment also indicated no alternatives had been attempted before initiating the wander guard and that it was to be used at all times, while the questions about whether the device met the definition of a physical restraint were left unanswered. During observation, the resident was wearing the wander guard bracelet and stated staff had placed it on her wrist when she arrived at the facility. The resident stated she was able to go outside, but the alarm sounded when she walked through the doors and staff came to check on her. She stated she did not like wearing the device and wanted it removed because it prevented her from enjoying the outdoors. Nursing staff and social work staff stated wander guard assessments were to be completed on admission, quarterly, annually, and with significant changes, and the DON stated residents with wander guards should be reassessed quarterly to determine if the device was still needed. The social worker was unable to find documentation that reassessments had been completed, and staff stated the resident should have been reassessed around the quarterly mark.
Resident restrained with blanket tied to bed frame
Penalty
Summary
The facility failed to ensure a resident was free from physical restraints when a blanket was tied to the frame of the resident’s bed across the chest. The resident, R1, was a female with diagnoses including unspecified dementia with behavioral disturbance, congestive heart failure, atrial fibrillation, hypertension, hypothyroidism, Meniere’s disease, major depressive disorder with psychotic symptoms, and anxiety disorder. Her MDS documented a BIMS score of 10, indicating moderate cognitive impairment. Her record did not contain an assessment, physician’s order, or care plan for a restraint. According to the incident report and staff statements, a CNA tied the resident’s blanket to the bed frame in an effort to prevent the resident from getting up independently and potentially falling. The CNA acknowledged prior education on abuse prevention and understood that physical restraints are considered abuse. The CNA also reported that she informed the nurse on duty of her actions. The facility’s investigation concluded that the CNA deliberately tried to physically restrain the resident and that the CNA was no longer employed. Other staff described finding the blanket tied to the bed frame when the resident was being gotten up in the morning. One CNA stated the blanket was tied so tightly she could not untie it and had to get the nurse. The LPN stated the blanket was tied at the level of the resident’s chest and that anything tied on the bed that impedes movement is a restraint. The DON stated the CNA said she tied one side of the blanket to the bed and tucked the other side in to prevent the resident from falling. The resident was unable to explain what happened when interviewed.
Seatbelt Used Without Required Restraint Assessment or Consent
Penalty
Summary
The facility failed to ensure a seatbelt was assessed as a potential restraint and that consent was obtained from the resident and/or the resident’s representative before use. Resident #6 was admitted and later readmitted with diagnoses including aftercare following surgery on the skin and subcutaneous tissue and Parkinson’s Disease with dyskinesia. The resident was observed sitting in a power chair with a seatbelt on on two separate occasions, but the record did not include documentation that the resident was assessed before the seatbelt was used as a potential restraint. The facility’s Use of Restraints policy stated that a pre-restraining assessment and review must be completed before placing a resident in restraints and that restraints shall only be used upon a physician’s written order and after obtaining consent from the resident and/or representative. The ADON stated the resident should have been assessed and consent obtained before initiating the seatbelt use and was unable to find documentation that this had occurred.
Missing physician order for abdominal binder restraint
Penalty
Summary
The facility failed to ensure appropriate items were in place for a resident with a restraint. Resident 1 had diagnoses including the presence of a gastrostomy tube for tube feeding. The resident’s care plan, initiated on November 24, 2014, directed that an abdominal binder be in place loosely enough to allow air to get to the area but close enough to prevent the resident from pulling the PEG tube out, with placement checked every shift. The care plan also stated that if the PEG tube came out, a Foley tube should be inserted to prevent the stoma from closing and the resident sent to the ER if dislodged. The resident’s physician orders included an order dated May 27, 2026, stating that the abdominal binder was to be on at all times, may be removed for care, and released every two hours every shift. Observation on May 28, 2026, at 10:00 a.m. showed an abdominal binder in place covering the resident’s PEG tube. Review of the clinical record failed to show a physician’s order for the abdominal binder restraint that had been initiated on November 24, 2014. The DON stated on May 29, 2026, that an audit of physician’s orders found no order existed for the resident’s abdominal binder restraint until May 27, 2026.
Improper Physical Restraint Used During Respiratory Treatment
Penalty
Summary
The facility failed to keep a resident free from the use of a physical restraint when RN#1 used a pillowcase to wrap around the resident’s left hand and tied it to the side rail during a nebulizer treatment. The resident was observed with the restraint by the hospice nurse, and the device was later removed by the Manager on Duty. The survey identified this as a deficiency involving 1 of 6 residents reviewed for restraint. The resident involved had diagnoses including unspecified dementia, major depression, respiratory failure, and functional quadriplegia. The resident’s MDS showed a BIMS score of 3 out of 15, indicating severely impaired cognition. The care plan identified the resident as resistive and combative with care related to cognitive loss/dementia, and the physician’s order summary included ipratropium-albuterol every 6 hours as needed for shortness of breath or wheezing. RN#1 stated the resident became combative and pulled off the nebulizer mask during the respiratory treatment, and she then secured the resident’s left hand to the side rail with a pillowcase to ensure the treatment was received. RN#1 later stated she should have called the medical doctor for refusal and documented the refusal. The facility reportable event and staff interview both confirmed that the resident’s left upper extremity had been secured to the enabler with a pillowcase during the treatment.
Physical restraint during refused care
Penalty
Summary
Freedom from physical restraint was not maintained when staff forcibly held a resident down after repeated refusals of incontinent care. The resident had diagnoses including myopathy and essential hypertension, and a recent MDS documented a BIMS score of 11 out of 15, indicating moderate cognitive impairment. The care plan noted behavioral symptoms such as refusing care, becoming combative during care, and frequent refusal of incontinent and hygiene care, with interventions directing staff to allow choices, avoid arguing, approach later if combative, and provide peri-care as the resident would allow. On the day of the incident, the resident refused care on multiple occasions. CNA #64 reported that she attempted to check the resident’s brief, was refused, and returned twice more with the same result before informing RN #63. RN #63 then directed CNA #64 to gather supplies and return to assist with care. During the attempt to provide care, the resident became physically aggressive, and staff continued with the interaction rather than stopping after the refusals. Witness statements described RN #63 directing continued care and stating the resident had to be changed, while CNA #64 stated she followed RN #63’s instructions and believed the resident could no longer refuse care. The resident reported that RN #63 and CNA #64 came into the room, held him/her down, grabbed his/her arms, ripped off clothing, and washed him/her with a cold rag. The resident’s daughter reported being told that staff held the resident down, and a police report documented visible fresh bruising to the wrists and hands. A clinical assessment found bilateral bruising and redness to the wrist area, discoloration to both hands, soreness to touch, and emotional distress with tearfulness when recalling the event. RN #63 denied restraining the resident and stated she was guarding herself and CNA #64 from the resident’s aggressive actions, but the investigation substantiated the incident as physical abuse.
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