Improper Use of Physical Restraint on Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when nursing staff failed to ensure a resident was free from the use of physical restraints, except as required for medical treatment. The incident involved a resident with Alzheimer's disease, parkinsonism, acute kidney failure, and a history of cerebrovascular accident with right-sided hemiplegia, who was cognitively impaired and non-ambulatory at the time, with a cast on the right lower leg. On the overnight shift, the resident was placed in a wheelchair and positioned in the dayroom by a CNA, who, after consulting with a nurse, wrapped a bed sheet around the resident's chest, under the arms, and tied it behind the wheelchair to prevent the resident from getting up or slipping forward. Surveillance footage confirmed that the CNA initially wrapped the sheet around the resident and that the nurse approved the action by nodding. When the resident removed the sheet, the nurse reapplied and secured it to the wheelchair. The resident remained calm and showed no signs of distress during the incident. The restraint was discovered by a housekeeper, who reported it to the housekeeping supervisor, who in turn notified the nurse. The nurse then removed the sheet from the resident's wheelchair. Interviews with staff revealed that the CNA believed the use of the sheet was approved by the nurse and did not consider it a restraint, as the intention was to keep the resident safe from slipping. However, the facility's policy clearly prohibits the use of physical restraints for discipline or convenience and requires systematic evaluation and monitoring of any device that could constitute a restraint. The nurse later denied knowledge of the sheet, but this was contradicted by the video evidence showing her involvement in both approving and reapplying the restraint.