Unauthorized Use of Physical Restraint on Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) wrapped a bed sheet around a resident with severe cognitive impairment, from under the chest to below the buttocks, to prevent the resident from accessing the area of their incontinent brief. The resident, diagnosed with Alzheimer's Disease and requiring substantial to maximal assistance with toileting hygiene, was found by another CNA in the morning with the sheet tightly wrapped around their body. The resident was unable to remove the sheet independently due to cognitive and physical limitations, and the sheet restricted the resident's ability to touch their mid-torso and brief area. The facility's abuse prevention policy defines misuse of restraints as any material attached or adjacent to a resident's body that cannot be easily removed and restricts freedom of movement or normal access to one's body, especially when not ordered by a medical provider or included in the plan of care. The resident's plan of care did not include the use of restraints, and there was no medical order for such an intervention. The CNA who applied the restraint did not notify the nurse or any other staff about the resident's behavior or the use of the bed sheet as a restraint. Interviews with staff confirmed that the CNA wrapped the sheet to prevent the resident from accessing feces in the brief, following episodes of diarrhea and fecal smearing. The incident was discovered during morning care, and staff agreed that the resident would not have been able to remove the sheet independently. The use of the bed sheet in this manner was not authorized and constituted a physical restraint, contrary to facility policy and regulatory requirements.