Failure to Prevent Unauthorized Use of Physical Restraint
Penalty
Summary
A resident with cerebral palsy, intellectual disabilities, and moderately impaired cognition (BIMS score of 09) was physically restrained multiple times over the course of several hours. The facility's policy required that physical restraints not be used unless there was an emergency, and only after thorough discussion with the resident or their representative and obtaining written consent. Documentation showed that the resident engaged in repeated self-harm behaviors, including putting fingers down their throat to induce vomiting, and was subsequently placed in a wrist restraint following a nurse practitioner's order. The restraint was applied, removed, and reapplied several times as the resident continued to display self-harming behaviors and aggression toward staff. There was no documentation indicating that the required discussion with the resident or their representative occurred, nor that written consent was obtained prior to the use of the restraint. Family members observed the resident restrained and reported that the resident appeared distressed and complained of stomach pain. Facility staff, including the MDS coordinator, indicated that restraints were not to be used in the facility and were unaware of any restraints being available. The use of the restraint was not consistent with facility policy, and the resident's representative was not involved in the decision-making process as required.