Failure to Prevent Physical Restraint and Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment and dementia from abuse in the form of physical restraint not required to treat medical symptoms. The incident involved two CNAs who were observed by a registered nurse holding the resident by the head, chest, arm, and feet in an attempt to keep her seated in a chair while she was agitated, screaming, and attempting to get up. The nurse intervened, instructed the CNAs to stop, and assisted the resident out of the chair. The resident was subsequently found to have bruising on her chest, right arm, and hand, as well as on her left forearm and hand. Staff interviews and record reviews confirmed that the CNAs physically restrained the resident, which was not permitted by facility policy and was not required for the resident's medical condition. The facility's policy defines abuse as the willful infliction of injury, and the DON and Administrator acknowledged that physically holding a resident in this manner would be considered a restraint and potentially abuse. The incident was under investigation at the time of the report, and the Administrator indicated it was being treated as an abuse case.