Use of Physical Restraint Without Medical Justification for Cognitively Impaired Resident
Penalty
Summary
A resident with diagnoses including Parkinson's disease, dementia, major depressive disorder, and unsteadiness on feet, who was severely cognitively impaired, was found to have the foot of his bed elevated and a pillow placed under his mattress to prevent him from getting out of bed during the night. The resident resided on a locked memory care unit and had been reported as restless, with multiple attempts to get out of bed during the night shift. Multiple staff members, including CNAs and an LPN, observed the elevated bed and pillow under the mattress during their morning rounds and reported these findings during shift change and in interviews. Staff interviews indicated that the interventions were not ordered for medical treatment and were instead used to inhibit the resident's freedom of movement. The staff did not admit to placing the pillow or elevating the bed, but these actions were identified as constituting a physical restraint. Facility policy defined such actions as unreasonable confinement and involuntary seclusion, and the incident was documented as a deficiency related to the use of restraints without appropriate medical justification.