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F0604
G

Resident Subjected to Physical and Chemical Restraint by Private Caregiver and Staff

Elizabeth City, North Carolina Survey Completed on 05-21-2025

Penalty

Fine: $16,720
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A severely cognitively impaired resident with diagnoses including metabolic encephalopathy, Alzheimer's disease, dementia with behaviors, and anxiety disorder was subjected to both physical and chemical restraint during an incident involving a private duty caregiver and facility staff. The resident, who had a history of refusing medications, was approached by a nurse to take her scheduled medication, which she refused. The private duty caregiver then intervened, attempting to force the medications into the resident's mouth, holding her hand over the resident's mouth to force her to swallow, and physically restraining the resident by placing her leg over the resident's legs to prevent kicking. The nurse instructed the caregiver to stop but left the room to call the on-call provider, during which time the caregiver continued to restrain the resident. Upon the nurse's return, the resident was still being physically restrained by the caregiver. The nurse then administered an intramuscular antipsychotic medication (Haldol) to the resident as a chemical restraint to calm her. Following the incident, a skin assessment revealed a small bruise on the resident's lower lip, and the resident was noted to have multiple bruises on her upper extremities, though some predated the incident. Interviews with staff confirmed the sequence of events, including the use of both physical and chemical restraints by the caregiver and nurse, respectively. The incident was witnessed by multiple staff members, including a nursing assistant who corroborated the use of force and restraint by the caregiver. The Director of Nursing and Medical Director were notified and assessed the resident after the event, noting the presence of bruising but no ongoing pain or decline in physical functioning. The administrator was also informed and confirmed the details of the incident, including the inappropriate actions of the private caregiver and the subsequent administration of a chemical restraint by nursing staff.

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