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:
A resident with dementia, anxiety, depression, and diabetes was kept on a wander guard that restricted access to the outdoors, but the facility did not document the required reassessment of continued need. The resident stated she disliked wearing the device and wanted it removed because it prevented her from enjoying the outdoors, while staff and the DON acknowledged the device should have been reviewed quarterly and could not find documentation of a reassessment.
A resident with dementia and moderate cognitive impairment was found with a blanket tied to the bed frame across the chest, despite no restraint order, assessment, or care plan in the record. A CNA admitted she tied the blanket to keep the resident from getting up and potentially falling, and staff later described the blanket as tightly secured and functioning as a restraint. The LPN and DON both acknowledged that tying the blanket to the bed was not appropriate and constituted a restraint.
Seatbelt Used Without Required Restraint Assessment or Consent: A resident with Parkinson’s disease and post-surgical diagnoses was observed sitting in a power chair with a seatbelt on, but the record lacked documentation of a pre-restraint assessment or consent from the resident or representative before the seatbelt was used as a potential restraint. The ADON stated the resident should have been assessed and consent obtained, but could not find documentation that this occurred.
A resident with a PEG tube had an abdominal binder in place to prevent pulling out the tube, and the care plan directed that it be worn loosely and checked every shift. The record showed the binder was being used as a restraint, but no physician order was found for its use until much later, and the DON confirmed the order had not existed when the restraint was initiated.
Improper Physical Restraint Used During Respiratory Treatment: An RN secured a resident’s left hand to the side rail with a pillowcase while attempting to administer a nebulizer treatment after the resident became combative and removed the mask. The resident had dementia, severe cognitive impairment, respiratory failure, and functional quadriplegia, and the restraint was later observed by the hospice nurse and confirmed in the facility’s event investigation.
A resident with moderate cognitive impairment and a care plan addressing refusals of care was forcibly held down by an RN and CNA after refusing incontinent care multiple times. During the interaction, the resident became physically aggressive, but staff continued the care, with witness statements describing the RN directing that the resident had to be changed. The resident later reported being held down, having arms grabbed, clothing ripped off, and being washed with a cold rag; bruising, wrist redness, hand discoloration, soreness, and emotional distress were documented.
Failure to Reassess Continued Need for Wander Guard
Penalty
Summary
The facility failed to monitor and reevaluate the continued need for a wander guard used to restrict a resident from accessing the outdoors for 1 of 1 resident reviewed for restraints. The resident had moderate cognition, was independent with activities of daily living, and had diagnoses including dementia, anxiety, depression, and diabetes. The resident’s quarterly MDS identified daily use of a wander/elopement alarm, and the restraint/adaptive equipment assessment noted use of antidepressants, antipsychotics, anxiolytics, and narcotics, along with a recent decline in condition, but did not specify the decline. The assessment also indicated no alternatives had been attempted before initiating the wander guard and that it was to be used at all times, while the questions about whether the device met the definition of a physical restraint were left unanswered. During observation, the resident was wearing the wander guard bracelet and stated staff had placed it on her wrist when she arrived at the facility. The resident stated she was able to go outside, but the alarm sounded when she walked through the doors and staff came to check on her. She stated she did not like wearing the device and wanted it removed because it prevented her from enjoying the outdoors. Nursing staff and social work staff stated wander guard assessments were to be completed on admission, quarterly, annually, and with significant changes, and the DON stated residents with wander guards should be reassessed quarterly to determine if the device was still needed. The social worker was unable to find documentation that reassessments had been completed, and staff stated the resident should have been reassessed around the quarterly mark.
Resident restrained with blanket tied to bed frame
Penalty
Summary
The facility failed to ensure a resident was free from physical restraints when a blanket was tied to the frame of the resident’s bed across the chest. The resident, R1, was a female with diagnoses including unspecified dementia with behavioral disturbance, congestive heart failure, atrial fibrillation, hypertension, hypothyroidism, Meniere’s disease, major depressive disorder with psychotic symptoms, and anxiety disorder. Her MDS documented a BIMS score of 10, indicating moderate cognitive impairment. Her record did not contain an assessment, physician’s order, or care plan for a restraint. According to the incident report and staff statements, a CNA tied the resident’s blanket to the bed frame in an effort to prevent the resident from getting up independently and potentially falling. The CNA acknowledged prior education on abuse prevention and understood that physical restraints are considered abuse. The CNA also reported that she informed the nurse on duty of her actions. The facility’s investigation concluded that the CNA deliberately tried to physically restrain the resident and that the CNA was no longer employed. Other staff described finding the blanket tied to the bed frame when the resident was being gotten up in the morning. One CNA stated the blanket was tied so tightly she could not untie it and had to get the nurse. The LPN stated the blanket was tied at the level of the resident’s chest and that anything tied on the bed that impedes movement is a restraint. The DON stated the CNA said she tied one side of the blanket to the bed and tucked the other side in to prevent the resident from falling. The resident was unable to explain what happened when interviewed.
Seatbelt Used Without Required Restraint Assessment or Consent
Penalty
Summary
The facility failed to ensure a seatbelt was assessed as a potential restraint and that consent was obtained from the resident and/or the resident’s representative before use. Resident #6 was admitted and later readmitted with diagnoses including aftercare following surgery on the skin and subcutaneous tissue and Parkinson’s Disease with dyskinesia. The resident was observed sitting in a power chair with a seatbelt on on two separate occasions, but the record did not include documentation that the resident was assessed before the seatbelt was used as a potential restraint. The facility’s Use of Restraints policy stated that a pre-restraining assessment and review must be completed before placing a resident in restraints and that restraints shall only be used upon a physician’s written order and after obtaining consent from the resident and/or representative. The ADON stated the resident should have been assessed and consent obtained before initiating the seatbelt use and was unable to find documentation that this had occurred.
Missing physician order for abdominal binder restraint
Penalty
Summary
The facility failed to ensure appropriate items were in place for a resident with a restraint. Resident 1 had diagnoses including the presence of a gastrostomy tube for tube feeding. The resident’s care plan, initiated on November 24, 2014, directed that an abdominal binder be in place loosely enough to allow air to get to the area but close enough to prevent the resident from pulling the PEG tube out, with placement checked every shift. The care plan also stated that if the PEG tube came out, a Foley tube should be inserted to prevent the stoma from closing and the resident sent to the ER if dislodged. The resident’s physician orders included an order dated May 27, 2026, stating that the abdominal binder was to be on at all times, may be removed for care, and released every two hours every shift. Observation on May 28, 2026, at 10:00 a.m. showed an abdominal binder in place covering the resident’s PEG tube. Review of the clinical record failed to show a physician’s order for the abdominal binder restraint that had been initiated on November 24, 2014. The DON stated on May 29, 2026, that an audit of physician’s orders found no order existed for the resident’s abdominal binder restraint until May 27, 2026.
Improper Physical Restraint Used During Respiratory Treatment
Penalty
Summary
The facility failed to keep a resident free from the use of a physical restraint when RN#1 used a pillowcase to wrap around the resident’s left hand and tied it to the side rail during a nebulizer treatment. The resident was observed with the restraint by the hospice nurse, and the device was later removed by the Manager on Duty. The survey identified this as a deficiency involving 1 of 6 residents reviewed for restraint. The resident involved had diagnoses including unspecified dementia, major depression, respiratory failure, and functional quadriplegia. The resident’s MDS showed a BIMS score of 3 out of 15, indicating severely impaired cognition. The care plan identified the resident as resistive and combative with care related to cognitive loss/dementia, and the physician’s order summary included ipratropium-albuterol every 6 hours as needed for shortness of breath or wheezing. RN#1 stated the resident became combative and pulled off the nebulizer mask during the respiratory treatment, and she then secured the resident’s left hand to the side rail with a pillowcase to ensure the treatment was received. RN#1 later stated she should have called the medical doctor for refusal and documented the refusal. The facility reportable event and staff interview both confirmed that the resident’s left upper extremity had been secured to the enabler with a pillowcase during the treatment.
Physical restraint during refused care
Penalty
Summary
Freedom from physical restraint was not maintained when staff forcibly held a resident down after repeated refusals of incontinent care. The resident had diagnoses including myopathy and essential hypertension, and a recent MDS documented a BIMS score of 11 out of 15, indicating moderate cognitive impairment. The care plan noted behavioral symptoms such as refusing care, becoming combative during care, and frequent refusal of incontinent and hygiene care, with interventions directing staff to allow choices, avoid arguing, approach later if combative, and provide peri-care as the resident would allow. On the day of the incident, the resident refused care on multiple occasions. CNA #64 reported that she attempted to check the resident’s brief, was refused, and returned twice more with the same result before informing RN #63. RN #63 then directed CNA #64 to gather supplies and return to assist with care. During the attempt to provide care, the resident became physically aggressive, and staff continued with the interaction rather than stopping after the refusals. Witness statements described RN #63 directing continued care and stating the resident had to be changed, while CNA #64 stated she followed RN #63’s instructions and believed the resident could no longer refuse care. The resident reported that RN #63 and CNA #64 came into the room, held him/her down, grabbed his/her arms, ripped off clothing, and washed him/her with a cold rag. The resident’s daughter reported being told that staff held the resident down, and a police report documented visible fresh bruising to the wrists and hands. A clinical assessment found bilateral bruising and redness to the wrist area, discoloration to both hands, soreness to touch, and emotional distress with tearfulness when recalling the event. RN #63 denied restraining the resident and stated she was guarding herself and CNA #64 from the resident’s aggressive actions, but the investigation substantiated the incident as physical abuse.
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