Failure to Prevent Unauthorized Use of Physical Restraints
Penalty
Summary
A deficiency occurred when staff failed to ensure a resident was free from physical restraints, as required by facility policy and federal regulations. The resident, who had severe cognitive impairment and multiple diagnoses including bipolar disorder and chronic pain syndrome, was admitted with significant assistance needs for daily activities. On the night in question, the resident became agitated, was kicking during care, and was not redirectable. In response, a registered nurse and a certified nurse assistant restrained the resident by wrapping and tying a bed sheet around the resident's legs and securing it to the bed frame to restrict movement and prevent falls. Prior to applying the restraint, staff did not assess the resident for possible causes of the behavior, nor did they attempt less restrictive interventions. The physician was not notified of the resident's continued agitation, and no physician order was obtained for the use of physical restraints. Additionally, there was no care plan developed to address the need for restraints, and the resident's responsible party was not informed. The medication Lorazepam was administered but was reported as ineffective by the nurse, although the medication administration record indicated it was effective. The restraint was discovered by another CNA and a certified occupational therapist assistant during morning rounds, at which point the restraint was removed and reported to a licensed vocational nurse. Interviews with staff and facility leadership confirmed that the use of the restraint was not in accordance with facility policy, which requires assessment, physician order, and use of the least restrictive alternatives. Staff involved acknowledged that the restraint was applied without proper procedures and that it was poor judgment.