Resident Physically Restrained by CNA Using Nightgown and Blanket
Penalty
Summary
A resident with Alzheimer's disease, hemiplegia, hemiparesis, major depressive disorder, and aphasia, who required total assistance for lower torso care and had a history of tearing apart incontinence briefs, was physically restrained by a Certified Nursing Assistant (CNA) during a PM shift. The CNA tied the sleeves of the resident's nightgown closed with the resident's arms inside and tucked a blanket across the resident's lap and under both sides of the mattress. This action was taken after the resident repeatedly attempted to remove their brief. As a result, the resident was unable to access their hands, move freely in bed, or reach the call light. The restraint was discovered by a Licensed Practical Nurse (LPN) during a routine check on the next shift, approximately two and a half hours later. The LPN found the resident with their arms inside the nightgown and a blanket tucked under the mattress, immediately untied the sleeves, and provided care. The resident was assessed for physical and psychological harm, with no new injuries noted, although bruising was observed on the tops of the resident's hands, which was determined not to be new. The resident, when interviewed, was only able to provide limited responses but indicated feeling fine and not having been hurt. Staff interviews and record reviews confirmed that the CNA had restrained the resident to prevent them from tearing at their brief and throwing items. The facility's policy prohibits the use of physical restraints for discipline or convenience and defines a physical restraint as any method that restricts freedom of movement or normal access to one's body. The CNA acknowledged in a statement that tying the sleeves was a poor decision, and the facility determined that the resident had been restrained during the last rounds of the PM shift.
Removal Plan
- Initiated physical and psychosocial monitoring for R1.
- Completed skin assessment for other cognitively impaired residents.
- Notified CNA-C's staffing agency and did not allow CNA-C to return to the facility.
- Educated facility and agency staff on the facility's abuse and restraint policies.