Failure to Ensure Residents Are Free from Physical Restraints Not Medically Required
Penalty
Summary
The facility failed to ensure that two residents were free from physical restraints not required to treat medical symptoms. Both residents were admitted under the custody of the United States Marshal Service and were continuously shackled at the wrists, ankles, and abdomen, and supervised by armed guards. The use of these restraints was not based on medical necessity, and there were no physician orders or consents for their application documented in the residents' records. Record reviews showed that the care plans for both residents acknowledged the presence of shackles and the requirement for constant supervision by U.S. Marshals, as mandated by law enforcement and court orders. Nursing staff were instructed to monitor for skin impairment related to the restraints and to notify the Marshal's nurse case manager and assigned physician if any skin issues arose. Observations confirmed that both residents remained restrained in their rooms, with guards present at all times, and that the restraints were only temporarily loosened for specific activities such as meals. Interviews with nursing staff, facility administration, and law enforcement personnel confirmed that the restraints were applied and maintained by the Marshal Service, not the facility itself. However, the facility accepted the residents for care under these conditions without obtaining the required medical orders or consents for the restraints, as outlined in the facility's own restraint management policy. The policy emphasizes a restraint-free environment and requires that restraints only be used to treat medical symptoms with proper orders.