Resident Restrained with Gown Without Proper Authorization
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
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Body pillows were used as restraints for three residents with significant cognitive and mobility impairments. Staff placed body pillows under sheets or tightly against the bed to keep residents in bed or prevent them from removing the pillows, and an NA stated this was done so a resident would not try to get out of or roll out of bed. The LPN and DON stated that placing body pillows this way made them a restraint.
Failure to assess whether a mattress bolster was a restraint for a resident with dementia, anemia, and HTN. The resident’s care plan included bolsters to bed for fall risk, and staff observed the resident in bed with bilateral raised mattress edges, but the record had no assessments or ongoing evaluations of bolster use. A UM confirmed the facility did not assess the resident’s functional status to determine whether the bolster was a restraint.
Improper Use of Roll Bolster as a Physical Restraint: A resident with dementia and severe cognitive impairment was observed with a Roll Bolster secured along the side of the bed, limiting the ability to sit up, stand, or get out of bed independently. Staff stated it was being used to prevent the resident from rolling over and exiting the bed, but there was no physician order, no documented use of alternative measures, no informed consent from the responsible party, and no care plan for the device. The facility policy identified such a device as a physical restraint when it restricts movement.
A resident with epilepsy and profound intellectual disabilities remained in a padded wheelchair with a lap belt and helmet, but staff did not release the belt during supervised care and meals. The DON stated the belt should be released when supervised and at least every two hours, yet the restraint reduction assessment was copied from an older date and staff said they had not tried to reduce the restraint because the resident’s epilepsy had not changed.
Failure to Complete Quarterly Restraint Reassessments: A resident with quadriplegia, muscle weakness, and impaired mobility used a wheelchair seat belt and lap tray, and observations showed both devices in place while the resident was in a power wheelchair. Although the care plan addressed the seat belt and noted the resident could independently lock and release it, the EMR showed the last restraint quarterly assessment was completed months earlier, with no later reassessment documented. RN and DON interviews confirmed the quarterly reassessment was expected but had not been completed.
A resident with intact cognition and behavioral symptoms including paranoia, hallucinations, and attempts to leave the building became highly agitated, pulled fire alarms, entered other residents’ rooms, and handled a fire extinguisher. Video and staff statements showed an LPN/CNA physically held the resident by the wrist, waist, and back while escorting the resident to the room, despite no order authorizing restraint and the resident not consenting to the contact.
Body pillows used as restraints
Penalty
Summary
The facility failed to ensure body pillows used as positioning devices were not implemented as physical restraints for 3 of 3 residents reviewed for restraints. R5 had diagnoses including a right femur fracture, osteoarthritis, dementia, osteoporosis, and a history of falling. After a witnessed fall, staff placed a body pillow under the sheets to prevent further self-ambulation, and the fall care plan was revised to include the body pillow under the sheets. R5 later had another incident in which she was found on the floor at the foot of the bed after family had placed her in bed without staff assistance. R11 had diagnoses of hemiplegia and hemiparesis affecting the left side and dementia. Her fall review identified her as at risk for falls due to scheduled narcotics, psychotropics, bowel and bladder incontinence, and being alert but unaware of mobility limitations. Her care plan included a body pillow for repositioning when in bed. During observation, staff placed a body pillow between R11 and the side of the bed underneath the sheet and tucked it securely into place, and the NA stated the body pillow was used to keep R11 in bed. R10 had diagnoses of hemiplegia and hemiparesis following cerebral infarction. Her MDS identified moderate cognitive impairment, daily physical and verbal behaviors, daily rejection of care, and need for substantial to maximum assistance with bed mobility and transfers. Her care plan included body pillows to outline the mattress parameter. During observation, a body pillow was tucked under the mattress sheet on the side of the bed, and the NA stated it was placed tightly so R10 would not remove it and so he would not attempt to get out of or roll out of bed. The nurse manager and DON stated body pillows should never be placed under the sheets to keep residents from getting out of bed and that doing so made the body pillow a restraint.
Failure to Assess Mattress Bolster as a Possible Restraint
Penalty
Summary
The facility failed to assess the functional status of Resident R23 to determine whether the use of a bolster on the mattress was a restraint. Facility policy defined physical restraints as any method or device attached to or adjacent to the resident’s body that the individual cannot remove easily and that restricts freedom of movement or normal access to the body. Resident R23’s record showed admission to the facility, diagnoses of high blood pressure, dementia, and anemia, and a physician order for a bolster mattress to bed dated 12/23/24. Resident R23’s care plan identified the resident as high risk for falls related to confusion, psychoactive drug use, a history of a fall at home with left hip fracture, and poor balance and safety awareness, with interventions including bolsters to bed when in bed. During observation on 6/23/26 at 9:47 a.m., Resident R23 was lying in bed with a mattress that had bilateral raised edges on the top and bottom portions. The clinical record did not identify any assessments or ongoing evaluations for the use of bolsters on the resident’s mattress, and a Unit Manager confirmed on 6/26/26 at 9:26 a.m. that the facility failed to assess whether the bolster was a restraint for the resident.
Improper Use of Roll Bolster as a Physical Restraint
Penalty
Summary
Resident 67 was observed with a Roll Bolster secured to the left side of the bed, extending from the shoulder to the lower extremities and restricting the resident’s ability to sit up, stand, or reposition independently. The resident was admitted with diagnoses including dementia, fracture of the left humerus, and muscle wasting, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated severely impaired cognitive skills and moderate assistance was needed with ADLs. The facility used the Roll Bolster to prevent the resident from getting out of bed and rolling over, but the record review found no physician order for the device, no documented evidence that alternative measures were used before it was placed, and no informed consent from the responsible party. During interviews, staff stated the bolster was being used to keep the resident from getting out of bed, and the DON confirmed there was no documented physician order, no informed consent, and no care plan developed for the use of the Roll Bolster. The facility’s policy stated that any mechanical device attached to or adjacent to a resident’s body that restricts freedom of movement is a physical restraint and requires a physician’s order, informed consent, documentation, care planning, ongoing monitoring, and periodic reevaluation. The RDCO stated that if the bolster inhibits the resident’s ability to get out of bed, it is considered a restraint, and the DON stated staff should have obtained a physician’s order, consent, and notified the resident or responsible party before placing any restraint.
Failure to Reduce and Release Wheelchair Lap Belt
Penalty
Summary
The facility failed to attempt a reduction of a resident’s restraint and failed to release the restraint when the resident was supervised. Resident R3 had diagnoses including epilepsy, profound intellectual disabilities, dysphagia, osteoporosis, and acute kidney failure, and was using a lap belt while seated in a padded wheelchair along with a protective helmet. During observation at lunch, R3 remained in the wheelchair with the seatbelt in place while staff removed the helmet and assisted with feeding; the seatbelt was not released during the supervised meal. Staff stated the helmet is removed at lunch and that the new padded wheelchair was helping with positioning, and they reported that R3 rarely scoots anymore and only needed repositioning once earlier. Record review showed the restraint reduction assessment was dated 10/7/25 and stated R3 continued to require the lap belt because of poor trunk control, spastic involuntary movements, and seizures, with the belt released under direct supervision and by the resident’s mother. The progress notes from 1/1/26 through 6/23/26 did not show any falls from the padded reclining wheelchair. The DON stated the seatbelt should be released at least every two hours and when R3 is supervised, but also stated the assessment had been copied and pasted and that R3’s epilepsy diagnosis had not changed, so they had not tried to reduce the restraint. The care plan stated R3 needed the lap belt and helmet when left unattended in the wheelchair, and the facility policy required the need for a restraint to be re-evaluated at least quarterly with efforts made to eliminate continued use.
Failure to Complete Quarterly Restraint Reassessments
Penalty
Summary
The facility failed to ensure ongoing assessment and evaluation of physical restraints for a resident who used a wheelchair lap tray and seat belt. The resident had intact cognition and diagnoses including quadriplegia, muscle weakness, lack of coordination, and abnormalities of gait and mobility. The quarterly MDS dated [DATE] identified that the resident did not use restraints, yet observations on 6/22/26 and 6/25/26 showed the resident seated and propelling in a power wheelchair with a secured seat belt and lap tray in place. The resident’s care plan dated 5/11/26 identified the seat belt use, noted the resident could lock and release it independently, and stated the resident had been educated on risks versus benefits and signed consent for use. The Physical Restraint Quarterly Assessment history showed the most recent assessment was completed on 2/17/26, and the EMR lacked evidence of any additional quarterly restraint assessments after that date. RN-A stated the nurse manager was responsible for reassessing continued need and ability to use the devices. The RNCM confirmed the assessment should have been completed after 2/17/26 and stated it had not triggered in the EMR system. The DON also confirmed another assessment should have been completed after 2/17/26 and stated quarterly assessments were expected to determine continued need, independent removal ability, and whether alternative interventions were needed.
Physical restraint used during behavioral episode
Penalty
Summary
The facility failed to keep a resident free from physical restraints during a behavioral episode. Resident #1 had a BIMS score of 13, indicating intact cognition, and diagnoses that included hypertension, arthritis, and COPD. The resident’s care plan documented paranoia, negative statements, medication and care refusals, attempts to leave the building, calling the police, hallucinations, and delusions, with interventions focused on reassurance, leaving and returning later, calm communication, diversion, and protecting other residents by removing the resident to another location. During the overnight incident, Resident #1 pulled fire alarms, entered other residents’ rooms, screamed for help, ripped a telephone off the wall, destroyed it, and grabbed a fire extinguisher and aimed it at residents and staff. Staff reports and video evidence showed that Staff B approached Resident #1 from behind, placed an arm around the resident’s back, held the resident’s wrist, and secured the resident’s waist while escorting the resident back to the room. The report states that Resident #1 did not consent to the physical contact and could not disengage, and that the hold continued as the resident was guided down the hallway and into the room. Staff statements described the contact as an attempt to prevent a fall or calm the resident, but the facility’s own restraint-free policy defined physical restraint to include holding down a resident in response to behavioral symptoms or during care when the resident resists or refuses care. The record review found no order authorizing staff to physically restrain Resident #1. Interviews with staff and the DON confirmed that the facility did not consider physical restraints acceptable practice, yet the documented actions during the incident included holding the resident by the wrist, waist, and back while the resident resisted, lowered to the floor, and refused to stand.
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