Failure to Ensure Residents Are Free from Physical Restraints Not Medically Required
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with leukemia, dementia, anxiety, and depression was observed in bed with a transfer pole on one side and a 1/4 bed rail on the other, which the facility’s Restraint Free Environment policy defined as a physical restraint. Facility policy required a comprehensive assessment and alignment with the care plan for assistive device use, but the resident’s record contained no restraint assessment or informed consent for the 1/4 bed rail. A CRN confirmed that no restraint assessments had been completed for this device, and the report notes this practice had the potential for physical and psychosocial harm if the resident were injured, trapped, or felt unnecessarily restrained.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
A resident with depression, muscle weakness, and dementia was kept on continuous bed and chair alarms ordered after a fall, but the orders lacked a related diagnosis, indication for use, and end date. The facility did not complete an initial physical restraint assessment, did not document that less restrictive interventions were tried and failed before using the alarms, and did not perform required quarterly restraint/device reassessments. IDT documentation referenced continuing the alarm but did not address alternatives, and fall assessments omitted any mention of the alarms, while the DON later acknowledged limited documentation and that the alarms did not appear necessary.
A resident with severe cognitive impairment, dementia, and behavioral symptoms including wandering was observed seated in a wheelchair at the dining table on multiple occasions with the wheelchair locked on one side. A CNA reported that the resident could not operate the wheelchair locks and that staff locked the wheelchair to keep the resident at the table and prevent wandering during meals, despite acknowledging staff were not supposed to lock it. Facility policy states residents must be free from physical restraints not required to treat a medical symptom, making this use of the wheelchair lock a noncompliant restraint.
A resident with multiple chronic conditions and intact cognition, care planned for fall risk and restful sleep, became agitated and combative during a night shift. After medication was given and the resident later transferred to bed, a CNA placed a mattress upright against one side of the bed and secured it with a locked chair, while the other side of the bed was against the wall, effectively preventing the resident from exiting the bed. Incoming CNAs observed the resident asleep with bedding and pillows arranged in a way that further restricted movement, and the DON confirmed the resident had been restrained in violation of the facility’s restraint policy.
A resident with severe cognitive impairment and BPH had an order for repeated UA with C&S. When the resident could not void into a urinal and verbally resisted catheterization by saying "Don’t do that" and crossing his legs, an LPN called two CNAs into the room. The CNAs held the resident’s arms and legs while the LPN performed an in-and-out catheterization to obtain the urine specimen. During the procedure, bright blood was observed in the catheter tubing and the procedure was stopped. Subsequent nursing notes documented the resident’s anxiety, later pain with urination, hematuria, and blood clots, leading to NP notification and hospital transfer. The facility’s investigation, including staff statements and a visitor account, concluded that the resident had been physically restrained against his will during the procedure, and the allegation of abuse by restraint was substantiated.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure a resident was free from the use of physical restraints unless needed for medical treatment by not assessing the safety of bed rail use or obtaining informed consent prior to use. Facility policy on Use of Assistive Devices, dated 12/29/25, required that assistive devices be used based on a comprehensive assessment and in accordance with the resident’s plan of care, and the Restraint Free Environment policy, reviewed 12/31/25, defined bed rails as a type of physical restraint. Resident #18, admitted with diagnoses including leukemia, dementia, anxiety, and depression, was observed in bed with a transfer pole on the left side and a 1/4 bed rail on the right side of the bed. Review of the resident’s record showed no documentation of a restraint assessment or consent form for the 1/4 bed rail, and on 4/3/26 the CRN confirmed that no restraint assessments had been completed for this bed rail. The report states this deficient practice had the potential for physical and psychosocial harm if the resident were injured, trapped, or felt she was being restrained unnecessarily. This deficiency was cross-referenced to F656.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
Failure to Assess and Justify Ongoing Use of Bed and Chair Alarms as Physical Restraints
Penalty
Summary
Surveyors found that a resident with diagnoses including major depressive disorder, muscle weakness, and dementia was subjected to ongoing use of a bed alarm and a pull (chair) alarm without proper assessment, documentation, or physician orders that met regulatory and facility policy requirements. The resident was observed with a pull alarm attached to her and her wheelchair, and a device connected to her bed. Physician orders dated 9/24/25 directed use of a pull alarm when in the wheelchair and a bed alarm when in bed every shift, but these orders lacked a related diagnosis or indication for use and had indefinite end dates. The alarms were initiated after a fall on 9/24/25, and the resident had no documented falls for more than seven months afterward, yet the alarms continued to be used. The facility’s documentation did not include an initial physical restraint assessment, did not show that least restrictive interventions were attempted and failed before initiating the alarms, and did not contain quarterly physical restraint/device reassessments as required by facility policy. An IDT note from 9/25/25 documented that the team met after the fall, noted placement of a pull alarm as an immediate intervention, and recommended continuing the alarm with routine evaluations, but did not discuss which less restrictive alternatives had been tried first. Fall assessments later provided by the facility did not mention the alarm devices. During interviews, the DON acknowledged there was little documentation about the devices, could not produce reassessments that addressed the alarms, and later stated it did not appear the resident needed the bed and chair alarms, while also asserting that the facility followed all federal and state regulations.
Improper Use of Wheelchair Lock as Physical Restraint During Meals
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from physical restraints not required to treat a medical symptom. The resident was admitted on 10/06/23 with diagnoses including unspecified dementia, hyperlipidemia, recurrent major depressive disorder, anxiety disorder, and cognitive communication deficit. A Minimum Data Set (MDS) assessment dated 02/02/26 documented that the resident was severely cognitively impaired, required set-up/clean-up assistance with eating, and was dependent for toileting, showering, and personal hygiene. The resident also exhibited occasional behaviors of physical aggression, verbal aggression, other behaviors, rejection of care, and wandering. On 03/11/26 at 10:34 A.M., the resident was observed alert, seated in a wheelchair at the dining room table, with the wheelchair locked on the left side. A subsequent observation at 11:49 A.M. the same day showed the resident still at the dining room table eating lunch in the same location, with the wheelchair again noted to be locked on the left side. During an interview at 2:22 P.M., a CNA stated that the resident was not able to lock or unlock the wheelchair and explained that staff locked the wheelchair to ensure the resident remained at the table and did not wander during meals. The CNA also verified that staff were not supposed to lock the wheelchair. The facility’s abuse and neglect policy states residents must be free from any physical restraint not required to treat a medical symptom, indicating that the practice of locking the wheelchair for behavior control was inconsistent with facility policy.
Resident Restrained in Bed Using Mattress and Chair Without Proper Authorization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from unnecessary physical restraints. The resident had diagnoses including cirrhosis with ascites, diabetes mellitus, COPD, and depression, with an MDS showing intact cognition, partial assistance with ADLs, supervision with transfers, and independence with bed mobility. The resident’s care plan addressed a need for restful sleep and identified fall risk, with interventions such as keeping the room quiet, dimming lights, offering a back rub or snack, and using a fall mattress on the floor next to the bed or a perimeter-defining mattress. On the night in question, nursing documentation indicated the resident became agitated, restless, combative, attempted to toss herself to the floor, and was yelling for her son. A hospice nurse assessed the resident and obtained an order for Ativan every four hours, after which the resident became calm. Later during the night shift, a CNA reported that the resident was restless, grabbing at the air, not responding to direction, and attempting to throw herself out of a chair. At approximately 5:45 a.m., this CNA transferred the resident to bed, covered her with a bedsheet, and placed a mattress upright against the open side of the bed, secured in place with the resident’s locked chair, while the other side of the bed was against the wall. Day-shift CNAs arriving later that morning observed the resident asleep in bed with a mattress pressed against one side of the bed, held in place by a locked chair, and the opposite side of the bed against the wall. One CNA reported that a sheet and blanket were tucked under the mattress over the resident, along with pillows positioned in a way that prevented the resident from exiting the bed, making it impossible for her to get out. Another CNA confirmed seeing the mattress and locked positioning chair against the bed. The DON confirmed that the facility verified the CNA had restrained the resident in bed by placing the mattress against the bed in this manner, resulting in the resident being unable to exit the bed, contrary to the facility’s policy that residents have the right to be free from physical restraints and that any ordered restraint must be the least restrictive and used for the least amount of time with ongoing reevaluation.
Resident Restrained for Urine Catheterization Resulting in Harm
Penalty
Summary
The deficiency involves facility staff physically restraining a cognitively impaired resident during an in-and-out catheterization to obtain a urine specimen, despite the resident’s resistance and inability to consent. The resident had benign prostatic hyperplasia and was documented as severely cognitively impaired on the admission MDS, with a BIMS score of 4/15 and always incontinent in the urinary continence section. A physician’s order directed that a urinalysis with culture and sensitivity be obtained every shift for three days. On the evening in question, the LPN attempted to obtain the ordered urine specimen via straight catheterization after the resident was unable to void into a urinal. According to the facility’s own investigation and staff statements, when the LPN entered the room to insert the catheter, the resident verbally resisted by saying “Don’t do that” and crossed his legs. The LPN then called for assistance from two CNAs. The visitor present was asked to leave the room, and while in the hallway, the visitor heard the resident yelling but could not make out the words. CNA statements and the facility’s synopsis of events documented that the two CNAs held the resident’s arms and legs while the LPN proceeded with the catheter insertion in order to obtain the urine specimen. The facility’s findings concluded that the CNAs did hold the resident’s extremities during the procedure and that the resident was restrained against his will. During the catheterization, bright blood was noted in the urine sample, and the LPN stopped the procedure when blood was seen entering the catheter tubing. Nursing notes documented that the resident appeared anxious but stable immediately afterward. Later that night and early the following morning, the resident experienced discomfort and pain with urination, with hematuria and blood clots noted in the brief, leading to notification of the on-call NP and transfer to the hospital. The facility’s grievance report and investigation summary documented that the catheter was used for a urine sample against the resident’s will, resulting in bleeding in the groin area and hospitalization, and that the allegation of abuse by restraint was substantiated based on staff interviews and the definition of abuse in the facility’s policy as willful infliction of injury or unreasonable confinement with resulting physical harm, pain, or mental anguish.
Removal Plan
- Staff members involved were placed on paid administrative leave pending investigation and subsequently terminated and reported to their respective licensing agencies.
- Immediate skin assessment completed on Resident 42; no skin impairment or changes noted.
- Resident 42 was evaluated by the facility social worker for psychosocial distress related to the incident; no distress was reported or observed.
- Residents with orders for straight catheterization were identified as potentially affected.
- Immediate skin checks were completed for all residents.
- Interviews were conducted with residents and no care issues or restraint issues were identified.
- CNAs, LPNs, RNs, Dietary, Social Services, Housekeeping, Therapy, Maintenance, Activities and MDS Coordinator were in serviced and educated on restraint policies and procedures and who the coordinator to whom concerns should be reported.
- Staff were educated on a resident's right to refuse or decline care and procedures and how nursing staff are to respond when a resident refuses care or treatment.
- Staff attending the training were educated to offer alternatives if possible and provide education on the needed treatment.
- New hire and annual training will be assigned and monitored for completion.
- Training regarding restraint use will be given for all new hires during orientation and annually for all employees.
- Resident grievances will be monitored continually for concerns regarding restraint use.
- The DON or designee will audit skin checks weekly for 50% of resident census to monitor for concerns.
- The Administrator or designee will conduct resident interviews to monitor satisfaction with care and monitor for reports of restraint use.
- Compliance and audit reports will be monitored through the facility QAPI program.
- The Administrator is responsible for ongoing compliance.
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