Improper Use of Physical Restraints on Resident
Summary
The facility failed to ensure that a resident was free from physical restraints imposed for purposes of discipline or convenience, which were not required to treat the resident's medical symptoms. On the specified date, a resident was observed on surveillance footage wandering the hallway and entering other residents' rooms. Security personnel and nursing staff attempted to restrain the resident by grabbing their wrists and physically holding them in place. Despite the resident's attempts to propel themselves away in a wheelchair, staff members continued to restrain the resident by holding onto their extremities. The resident, who was cognitively intact and had a history of mood issues, was negatively impacted by increased confusion and sundowning. The care plan for the resident included monitoring their mood and providing support, but specific approaches for managing the resident's behavior were not documented. During the incident, the resident was forcibly placed in a wheelchair and restrained by multiple staff members, which resulted in psychosocial harm and the potential for serious injury. Interviews with staff revealed that the resident was agitated and paranoid, believing that staff were trying to harm them. Despite attempts to administer medication, the resident refused oral medication and was given an intramuscular injection. The staff's actions, including physically restraining the resident and administering medication without proper consent, were not in line with the facility's policy of being a restraint-free environment. The incident was not reported to the facility administrator until three days later, indicating a delay in addressing the deficiency.
Penalty
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