Resident Restrained Without Order or Documentation
Penalty
Summary
A resident with hemiplegia, dementia, and aphasia was found to have a sock tied around his left hand, which was later discovered to be secured with an elastic waistband from underwear. This restraint was applied by a CNA without a physician's order, consent, or documentation. The resident's care plan did not include interventions for the use of a glove or sock to address his behavior of smearing feces, and there was no documentation in the clinical record regarding the use or release of the restraint. The incident was reported after the resident was found with swelling, red and purple areas, and linear indentations on his left hand and wrist, indicating injury from the restraint. Interviews revealed that the CNA applied the sock and elastic band after repeated episodes of the resident smearing feces and being unable to obtain a glove from nursing staff. The CNA did not inform the next shift about the restraint. The facility's policy states that residents have the right to be free from physical restraints used for staff convenience or discipline, and the restraint was not ordered or documented as required. The lack of appropriate assessment, documentation, and adherence to policy led to the resident being restrained without proper authorization or monitoring.