Resident Physically Restrained Without Clinical Justification or Use of Alternatives
Penalty
Summary
A deficiency occurred when a resident receiving hospice care was physically restrained by an LPN using a bed sheet tied around the resident's waist and secured to a wheelchair. The restraint was applied after the resident exhibited combative behavior, attempted to stand unassisted, and fell from the wheelchair. The resident was left unattended at the nurse's station, agitated, and reported severe pain. The restraint was discovered by a visiting hospice nurse, who found the resident unable to release himself and experiencing abdominal pain. The hospice nurse immediately untied the resident and stayed with him until his transfer out of the facility. Prior to the restraint, the resident had a history of anxiety, terminal illness, and recent behavioral changes, including agitation, restlessness, and combative actions such as pulling at his urinary catheter and attempting to stand or wander unsafely. The resident had multiple as-needed (PRN) medications ordered for pain, anxiety, and agitation, including Oxycodone, Ativan, Haldol, and Phenobarbital. Despite these available interventions, the LPN did not utilize the PRN medications or contact hospice for additional support before resorting to physical restraint. Documentation and interviews confirmed that the restraint was not ordered by a physician, was not part of the resident's care plan, and was not applied in accordance with facility policy, which prohibits restraints for staff convenience or as a substitute for other interventions. The facility's investigation into the incident was incomplete, as it did not include statements from hospice staff or a thorough review of hospice notes. The incident was not immediately reported to facility administration, and the final self-reported incident (SRI) was submitted before all relevant information was gathered. The facility's policy clearly defines physical restraint and outlines the requirements for its use, none of which were met in this case. The deficiency affected one resident, who was cognitively intact and receiving end-of-life care, and resulted in actual harm as the resident was physically restrained without appropriate clinical justification or adherence to policy.