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F0689
D

Resident Injured During Manual Restraint in De-escalation Incident

Santa Ana, California Survey Completed on 06-06-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a resident was free from injury during a de-escalation process, resulting in the resident sustaining multiple bruises and scratches to the face and neck. According to the facility's policy, the least restrictive method should be used to resolve situations, with manual restraint reserved for acute episodes of dangerous behavior. On the date of the incident, the resident became verbally aggressive and attempted to pour out a community water jug. Staff attempted therapeutic communication, which was unsuccessful, and the situation escalated to physical contact. During the struggle, the resident and staff fell to the ground, and staff manually restrained the resident by holding his limbs until he calmed down. Medical examination documented small bruises on the resident's left eyebrow and neck, as well as bruising and swelling around the nose bridge and a scratch on the forehead. Observations confirmed these injuries, and the resident reported being taken to the ground, choked, and having his head smashed into the ground by staff. Staff interviews corroborated that a physical altercation occurred, resulting in the resident being restrained on the ground. The DON confirmed that the injuries were not present upon admission and occurred during the incident on the patio.

An unhandled error has occurred. Reload 🗙