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F0604
D

Improper Use of Physical Restraint by CNA

Highland, California Survey Completed on 07-09-2025

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

A deficiency occurred when a Certified Nursing Assistant (CNA) physically restrained a resident by placing his arm over the resident's shoulders and holding him against a wall, restricting the resident's movement. The incident took place in a room with a vending machine, where the resident, who had a history of schizophrenia and functional dyspepsia, was found unsupervised. The CNA attempted to escort the resident out after a verbal altercation, during which the resident became agitated and used derogatory language. The CNA's actions escalated to physically restraining the resident, despite the resident not posing an imminent danger to himself or others. Facility records, including the nurse's progress notes and an event summary report, confirmed that the CNA's use of physical restraint was not consistent with facility policy, which only permits such interventions as emergency measures to protect from injury. The administrator acknowledged that the CNA did not follow proper procedures, as the situation did not warrant physical restraint. The facility's policy requires restrictive behavioral interventions to be used only when necessary for safety, which was not the case in this incident.

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