Improper Use of Physical Restraint with Tied Gown
Penalty
Summary
A resident with dementia, bipolar disorder, anxiety, and insomnia was found to have been placed in two gowns during the evening shift. The first gown was worn correctly, while the second, oversized gown was gathered and tied in a knot below the resident's knees and behind her neck. This was done by a CNA in response to the resident repeatedly lifting her gown and exposing herself in the hallway. The knotted gown restricted the resident's ability to reposition or straighten her legs, and she remained in this position throughout the evening and night shifts without opportunities for repositioning, incontinence care, or release of the restraint. The resident's care plans documented her severe cognitive impairment, dependence on staff for activities of daily living, and a history of removing clothes inappropriately. Despite these documented needs, the intervention used—tying the gown—was not part of her care plan and was not implemented to treat a medical symptom, but rather to prevent her from exposing herself. Staff involved were unaware that tying the gown in this manner constituted a physical restraint, and the resident was left in a semi-fetal position, unable to move freely or access her body for an extended period. Multiple staff interviews and documentation confirmed that the gown was tied tightly enough that significant effort was required to remove it, and the resident was found soiled and unable to straighten out her legs. The facility's policy clearly states that restraints are only to be used to treat medical symptoms and never for staff convenience or discipline. The use of the gown as a restraint in this case was not in accordance with policy, and the resident was deprived of necessary care and mobility as a result.