Use of Physical Restraint on Cognitively Impaired Resident
Penalty
Summary
Staff failed to ensure that a resident was free from the use of a physical restraint. The resident, who had severe cognitive impairment and multiple medical diagnoses including alcohol-induced persisting dementia, pathological fractures, and anxiety disorder, was observed to have limited upper body control and had experienced multiple falls. On the night in question, staff observed the resident slumped over in a wheelchair, unable to maintain an upright position. In response, a CNA suggested and, with the agreement of an LPN, wrapped a sheet around the resident and tied it to the wheelchair handles to prevent the resident from falling. Another CNA witnessed the resident being tied to the wheelchair and confirmed that the resident could not get out of the restraint, which was in place for approximately 15 minutes. Staff interviews revealed that the decision to use the sheet as a restraint was made out of concern for the resident's safety, despite awareness that such an action constituted the use of a physical restraint and was not in compliance with regulations. The LPN acknowledged that restraints were not permitted but allowed the use of the sheet to prevent a fall. The resident was later returned to bed and remained there until a subsequent fall was discovered. The incident was later confirmed by the facility's administrator during an investigation.