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NY State Tag
D

Resident Restrained for Convenience in Violation of Policy

Staten Island, New York Survey Completed on 04-07-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was treated with dignity and was free from physical restraints imposed for discipline or convenience. This deficiency was identified during an observation on the morning of October 26, 2024, when a resident was found lying in bed with their left ankle tied to the bed rail using a bed sheet. The restraint was applied by a Patient Care Technician who admitted to restraining the resident to prevent them from falling while attending to another resident. The resident involved had moderately impaired cognition and exhibited physical and verbal behaviors directed at others. Despite these behaviors, the restraint was not medically indicated and was applied for convenience, which is against the facility's policy. The incident was reported by another Patient Care Technician who discovered the restraint and immediately informed a Registered Nurse, who then removed the sheet and assessed the resident. The facility's investigation confirmed that the restraint was applied without mal-intent and did not result in physical, emotional, or psychological harm to the resident. However, it was acknowledged that the action was outside the facility's policy and procedure, which mandates that residents have the right to be free from physical restraints unless medically necessary.

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