Resident Physically Restrained During Incontinence Care
Penalty
Summary
A facility failed to ensure that a resident was free from physical restraint, as required by policy and regulation. During incontinence care, a certified nursing assistant (CNA) physically restrained a male resident with Alzheimer's Disease, ataxia, and severe cognitive impairment by pushing his hands into his chest and holding him down on the bed. The resident, who was dependent on staff for most activities of daily living and was always incontinent, became agitated and combative when awakened for care. Despite the resident's care plan specifying that staff should stop personal care and return later if he became agitated, the CNA continued to attempt care and used physical force to restrain the resident. The incident was witnessed by another CNA, who reported that the resident was startled awake, became combative, and grabbed her hand. The CNA observed her colleague restraining the resident and reported the behavior to the charge nurse. A video recording from the resident's in-room camera confirmed that the CNA held the resident down, and the resident could be heard expressing pain. Interviews with staff and the resident's responsible party corroborated the sequence of events, including the use of force and the resident's distress. The CNA involved was agency staff and had completed required training through the agency but had not previously worked at the facility. The facility's policy prohibits the use of restraints for discipline or convenience and limits their use to situations with a medical symptom warranting restraint. The actions taken by the CNA were not in accordance with the resident's care plan or facility policy, resulting in a deficiency related to the use of physical restraints.
Removal Plan
- CNA A was immediately removed from resident care and suspended then terminated.
- Appropriate notifications to abuse coordinator, RP and providers were made.
- Began ongoing in-service for all staff which covered abuse/neglect and required reporting to the facility abuse coordinator.
- Began ongoing in-service for all staff which covered using no force or minimal force with residents and reporting any pain during personal care to charge nurse. The in-service was provided to all-staff members.