NY State Tag

G

Improper Use of Chemical Restraint on Resident

New York State Veterans Home At MontroseMontrose, New York Survey Completed on 04-03-2025

Summary

The facility failed to ensure that a resident was free from chemical restraints imposed for purposes of discipline or convenience, which were not required to treat the resident's medical symptoms. The incident involved a resident who was observed wandering the unit and entering other residents' rooms. Despite being cognitively intact and having no documented medical symptoms or appropriate assessment for the use of antipsychotic medication, the resident was administered an intramuscular antipsychotic injection by staff members. The facility's policy, which emphasizes a restraint-free environment, was not adhered to in this situation.

The sequence of events began with the resident wandering and entering another resident's room, followed by attempts by staff to redirect the resident. The resident was then seen writing on a piece of paper at the nursing cart and later sitting in a recliner in the common area. Staff attempted to administer oral medication, which the resident refused and subsequently spit out. The situation escalated when staff physically restrained the resident against a wall, and an injection was administered without documented evidence of medical necessity or prior assessment.

Interviews with facility staff and the attending physician revealed that the physician was informed of the resident's agitation and paranoia, leading to an order for an intramuscular antipsychotic injection after oral medication was refused. However, the attending physician was not aware of the surveillance footage and stated that other interventions should have been attempted first. The facility's failure to follow its own policy and the lack of documented medical justification for the use of chemical restraint resulted in a deficiency that had the potential for serious harm to the resident.

Penalty

No penalty information released