Unauthorized Use of Physical Restraint for Resident with Dementia
Penalty
Summary
A resident with dementia, hearing loss, and major depressive disorder was admitted to the facility and was noted to be independent in bed mobility, transfers, and ambulation with a walker, but required supervision to prevent falls. The resident exhibited confusion, agitation, and restlessness, particularly in the evenings, but was assessed as low risk for safety concerns and did not require a safety plan. Despite this, staff placed the resident in a Broda chair, a specialized wheelchair, and secured the seat belt without a physician's order, justification, consent, or care plan. The decision to use the Broda chair was made by a charge nurse, who instructed certified nursing assistants to comply, and threatened staff with termination if they spoke out. Multiple staff interviews confirmed that the Broda chair was used to manage the resident's agitation and that the resident was unable to independently exit the chair when it was reclined. The Broda chair was not intended for behavioral management or fall prevention, and its use in this manner constituted a physical restraint. The facility's Director of Rehabilitation Services and other clinical staff confirmed that the Broda chair required a physician order, clinical evaluation, and monitoring, none of which were present in this case. The medical record lacked documentation of any order, justification, or care plan for the use of the Broda chair for this resident. Facility policy defined physical restraints as any device that restricted movement and could not be easily removed by the resident, and prohibited their use unless required to treat medical symptoms. The use of the Broda chair in this instance was not supported by clinical need or proper authorization, and staff education on abuse and restraint had been provided. The incident was later investigated by facility administration, but at the time of the event, required protocols and documentation were not followed.