Resident Restrained Without Physician Order or Assessment
Penalty
Summary
A resident with severe cognitive impairment and a diagnosis of dementia was admitted to the facility while restrained with abdominal and chest restraints. Upon admission, the admitting nurse untied the restraints to transfer the resident to the facility bed and then reapplied the restraints, confining the resident to the bed. The nurse did not obtain a physician order for the use of these restraints, nor was an assessment conducted to determine the necessity or safety of the restraint use as required by facility policy. During the evening, a CNA questioned the use of the restraints and was instructed by the LPN to keep the restraints in place after providing care, citing a lack of time to check on the resident frequently. Video review confirmed that the LPN did not check on the resident until several hours later, during the early morning medication pass. At shift change, the incoming LPN was not informed about the restraints and only discovered them during an assessment, at which point the restraints were immediately removed due to the absence of a physician order. Interviews with facility leadership and nursing staff confirmed that the general practice is to avoid the use of restraints and that any resident arriving with restraints should have them removed immediately pending assessment and physician evaluation. The admitting nurse acknowledged being aware of the restraints and applying them without proper authorization or assessment, which was corroborated by video evidence and staff interviews.