Resident Restrained During Podiatry Care Without Proper Assessment
Penalty
Summary
A resident with significant cognitive impairment, dementia, and diabetes was subjected to physical restraint during a podiatry care session. The facility's policy required that physical restraints only be used after assessment by the Interdisciplinary Team (IDT) and when alternatives had been deemed ineffective, but this process was not followed. The Charge Nurse made the unilateral decision to proceed with podiatry care despite the resident's history of resistance and recent refusals of such care. During the procedure, the Charge Nurse laid across the resident's lap and legs to prevent movement, while a Certified Occupational Therapy Assistant (COTA) and a Certified Nurse Aide (CNA) held the resident's hands. The resident verbally expressed refusal and distress multiple times, requesting for the care to stop and to be left alone. Staff interviews confirmed that the resident was agitated, combative, and verbally objected to the care, yet the procedure continued with physical restraint. The COTA reported feeling uncomfortable with the method used, as it limited the resident's mobility, and stated he would not have participated had he known restraint was being used as the only means to complete the care. The Charge Nurse later acknowledged that her approach was inappropriate and that the situation should have been handled differently, such as consulting a physician for alternative arrangements. The incident was reported internally and confirmed by multiple staff members.