Resident's Arm Improperly Restrained with Sock
Penalty
Summary
The facility failed to ensure a resident's right to be free from physical restraints not required to treat medical symptoms, as evidenced by an incident involving a resident whose left arm was tied to the siderail of their bed with a sock. This incident was discovered on the morning of October 4, 2023, when a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) found the resident in this condition. The resident reported being tied up all night and experiencing pain, although no bruises or injuries were observed, and an x-ray showed no fractures or dislocations. The facility's investigation revealed that the resident was under the care of a CNA during the night shift, who was later found not to have provided any care to the resident during their shift. Surveillance footage confirmed the lack of care provided. Another CNA, who was on the previous shift, was implicated in the incident after reportedly calling the facility the following morning and asking another CNA to check on the resident. This CNA was later identified as the last known staff member to have cared for the resident before the incident. The facility's policies on resident abuse and physical restraints, which emphasize the residents' right to be free from such restraints unless medically necessary, were not adhered to in this case. The Director of Nursing concluded that the CNA from the previous shift was responsible for restraining the resident, leading to their immediate removal from the schedule and subsequent termination. The incident highlights a significant breach of the resident's rights and the facility's failure to protect them from unauthorized restraints.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. The following actions were accomplished for the residents identified in the sample: Resident #1 On 10/4/23, the resident was seen and examined by the Assistant Director of Nursing Services (ADNS), with no visible signs of injury. The attending physician was notified, and an order for [REDACTED]. The resident does not exhibit any medical symptoms that would necessitate the use of a restraining device. On 10/4/23, the Social Work (SW) Director contacted the local police department to report the incident for further investigation. The case was subsequently referred to the district attorney's office for review. The resident was re-examined by the attending physician on 10/6/23, who reviewed the left-hand x-ray results. CNA #2 was terminated on 10/4/23. The Potential for Abuse Care Plan was reviewed on 12/16/24 and again on 2/25/25, the interdisciplinary team (IDT) determined that there was no need to revise the plan of care. The IDT continues to monitor for any signs or symptoms of abuse or unnecessary use of physical restraint devices. There have been no restraint concerns since this event in 2023. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents in the facility have been identified as potentially affected by the same practice. A comprehensive audit was conducted by the Nurse Supervisors and the Interdisciplinary Care Plan Team (IDCPT) on 02/25/2025 for all residents to identify any use of physical restraint devices. No residents were found to be using any physical restraint devices. III. The following system changes will be implemented to ensure continuing compliance with regulations: The Administrator, Director of Nursing (DNS), and Medical Director will review and revise, as necessary, the facility’s policies and procedures related to physical restraints. This review will include protocols for assessing the use of restraints, obtaining physician orders, securing resident representative consent, and ensuring proper care planning for restraints. The DNS/designee will continue to provide additional education to all staff regarding their responsibilities related to the policies and procedures for physical restraint. This education will be included in the orientation for new clinical team members and reviewed annually or as needed. RN Supervisors will monitor compliance through routine observational rounds and review physician orders [REDACTED]. Immediate corrective actions, including staff re-education and reassessment of restraints will be taken as needed. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with protocols related to the use of restraints. The DNS/designee will audit all residents identified with restraint devices monthly for the next 3 months, and then quarterly for the following 3 quarters. The DNS will report all restraint audit findings to the Administrator monthly for the first 3 months, and then at the end of each subsequent quarter for the next 3 quarters. Corrective actions, including education and obtaining physician orders [REDACTED]. The DNS will report all physical restraint audit findings to the QA Committee monthly for the first 3 months, and then at the end of each subsequent quarter for the next 3 quarters. At the end of this period, the Committee will evaluate the need for continued monitoring, determine the appropriate frequency, and decide on any additional corrective actions to implement.