Failure to Prevent Unnecessary Physical Restraint During Personal Care
Penalty
Summary
Staff failed to ensure a resident was free from unnecessary physical restraints during the provision of personal care. When the resident, who had severe cognitive impairment and a history of physical and verbal aggression, refused care and became combative, staff proceeded to hold the resident's wrists and restrain them in order to complete peri care. The resident was observed to be kicking, swinging, and biting during the incident, and staff did not follow the care plan, which instructed them to allow the resident to calm down and self-soothe when agitated or resistive to care. The facility's policies clearly defined physical restraint as any manual method that restricts a resident's freedom of movement, including holding a resident down during care if they are resistive or refusing. The care plan for the resident specified interventions such as giving choices, reducing stimulation, and stepping away to allow the resident to calm down if agitated. Despite these guidelines, staff continued to provide care while physically restraining the resident, rather than stopping and reapproaching later as directed by the care plan and facility policy. As a result of the incident, the resident sustained a skin tear to the chin, bruising on both hands, and scratches on the arms. The event was reported by the CNA involved, who described the nurse's actions in detail, including holding the resident's wrists, flipping the resident, and restraining the resident's legs. The nurse's own statement confirmed that care was provided despite the resident's resistance. The incident was corroborated by interviews and skin assessments, which documented the injuries sustained during the episode.