Failure to Protect Resident from Abuse through Improper Physical Restraint
Penalty
Summary
A resident with diagnoses including dementia and anxiety disorder, and severely impaired cognition as indicated by a Brief Interview for Mental Status score of 0 out of 15, was involved in an incident where staff failed to protect the resident from abuse. The resident, who was known to be at risk for self-care deficits and had care plan interventions to redirect and reapproach if resistive, became agitated and combative, attempting to enter another resident's room. Staff responded by physically escorting the resident to the common area and later to the resident's room. Multiple staff members, including a registered nurse and a licensed practical nurse, were observed by other staff to use excessive force and physical restraint on the resident. Witness accounts described the resident being dragged down the hallway by the arm and walker, forcefully pushed into a chair, and later thrown into bed and pinned down by the chest and head. Staff were also reported to have made statements indicating a punitive approach, and did not follow the care plan interventions of redirection and calm re-approach. The resident was visibly distressed and attempted to resist, including spitting and kicking at staff. The facility's own investigation, as well as staff interviews, substantiated that the actions taken by the staff constituted abuse, including the use of manual physical restraint and unreasonable confinement. The Director of Nursing confirmed that the staff did not follow expected procedures, such as monitoring the resident from a distance or leaving the resident alone once safe, and acknowledged that the resident was abused during the incident. The survey team concluded that the actions taken by staff resulted in a deficiency related to the failure to protect the resident from abuse.