Unauthorized Use of Physical Restraint with Sheet and Tape
Penalty
Summary
Facility staff failed to ensure a resident was free from the use of physical restraints when two CNAs wrapped a sheet around the resident's legs and secured it with tape to prevent the resident from removing his brief and smearing feces. The resident, who had severe cognitive impairment due to Parkinson's Disease, was found by an LPN tugging at the sheet, with his legs bound together by tape over the sheet. The intervention was not ordered by a physician, not included in the care plan, and there was no documentation of assessment or approval for the use of a physical restraint. The facility's policy defined physical restraints as any device or material that the resident cannot remove easily, and specifically prohibited practices such as tucking sheets to restrict movement. Interviews confirmed that the CNAs used the sheet and tape without authorization, and the DON and Administrator acknowledged the intervention was a violation of policy. The resident's arms and feet were not restricted, and a red area was noted on the leg, which resolved within an hour. There was no evidence of injury directly caused by the restraint, and the incident was not classified as abuse.