Resident Restrained with Gown Without Proper Authorization
Penalty
Summary
A deficiency occurred when a resident was found confined to a wheelchair using a hospital gown tied around their waist, which prevented the resident from moving freely. This action was discovered by a clinical team during routine rounds, and it was confirmed through interviews with the LVN/Treatment Nurse, the Director of Nursing (DON), and the Administrator. The staff involved acknowledged that using a gown in this manner constituted a physical restraint, and there was no physician's order or care plan authorizing the use of restraints for this resident. The resident involved had a history of dementia, cognitive impairment, hypertension, left lower leg contracture, lack of coordination, and a history of transient ischemic attack and cerebral infarction. The Minimum Data Set (MDS) indicated the resident had severely impaired cognitive skills and required substantial to total assistance with most activities of daily living. Despite these needs, the MDS and facility records showed that restraints were not ordered or care planned for this resident at the time of the incident. Facility policy explicitly prohibits the use of restraints for staff convenience or fall prevention and requires that all less restrictive alternatives be attempted before considering restraint use. The Certified Nurse Assistant (CNA) who tied the resident to the wheelchair admitted to using the gown to prevent the resident from falling, without following proper protocol or obtaining the necessary orders and consents. The facility's investigation confirmed that the CNA did not comply with policy, resident rights, or standard care protocols, resulting in the resident being physically restrained without appropriate justification or documentation.
Plan Of Correction
What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur? From July 10, 2025 to July 11, 2025, the Director of Staff Development (DSD) or designee conducted an in-service training for licensed nursing staff and Certified Nursing Assistants (CNAs). The training focused on the importance of ensuring that non-verbal residents are provided with an effective and reliable means of communication, in order to support continuous and timely interaction within the facility. Incoming admissions will be reviewed during the daily Interdisciplinary Team (IDT) Clinical Meeting to promptly identify non-verbal residents and ensure appropriate communication tools are made available. Any findings requiring additional follow-up will be reported to the Administrator for further review and action. How the facility plans to monitor its performance to make sure that solutions are sustained: The Administrator/designee will provide any negative findings to the QAPI committee monthly for three months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: July 11th, 2025 How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident 1 was immediately released from the wheelchair and appropriately assessed for injury on June 26, 2025. CNA 1 was terminated following the substantiated allegation of abuse. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On June 27, 2025, department supervisors conducted room rounds with residents and/or their responsible parties (RPs) to ensure there were no similar concerns regarding interactions with facility staff and to assess residents' perceptions of their safety within the facility. No additional concerns were identified during the review. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From June 26, 2025 to June 27, 2025, the Director of Staff Development (DSD), designee conducted multiple in-service trainings for licensed nursing staff and Certified Nursing Assistants (CNAs). The trainings emphasized the importance of implementing appropriate fall prevention interventions. In-services also covered the recognition and prevention of abuse, reinforcing staff responsibilities in reporting and maintaining resident safety. Training also highlighted the proper use of restraints, stressing that restraints must only be applied when absolutely necessary and always with a valid physician's order obtained prior to utilization along with informed consent. This training aimed to ensure compliance with facility policies and regulatory standards while promoting the health, safety, and dignity of residents. Any negative findings identified throughout daily operations from staff will be reported to the Administrator for further review and action in accordance with our abuse policy. How the facility plans to monitor its performance to make sure that solutions are sustained: The Administrator/designee will provide any negative findings to the QAPI committee monthly for three months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: June 27th, 2025 All residents have the potential to be affected by this deficient practice. On June 27, 2025, department supervisors conducted room rounds with residents and/or their responsible parties (RPs) to ensure there were no similar concerns regarding interactions with facility staff and to assess residents' perceptions of their safety within the facility. No additional concerns were identified during the review. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From June 26, 2025 to June 27, 2025, the Director of Staff Development (DSD), designee conducted multiple in-service trainings for licensed nursing staff and Certified Nursing Assistants (CNAs). The trainings emphasized the importance of implementing appropriate fall prevention interventions. In-services also covered the recognition and prevention of abuse, reinforcing staff responsibilities in reporting and maintaining resident safety. Training also highlighted the proper use of restraints, stressing that restraints must only be applied when absolutely necessary and always with a valid physician's order obtained prior to utilization along with informed consent. This training aimed to ensure compliance with facility policies and regulatory standards while promoting the health, safety, and dignity of residents. Any negative findings identified throughout daily operations from staff will be reported to the Administrator for further review and action in accordance with our abuse policy. How the facility plans to monitor its performance to make sure that solutions are sustained: The Administrator/designee will provide any negative findings to the QAPI committee monthly for three months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: June 27th, 2025