Resident Restrained with Tied Bed Sheet Without Assessment or Order
Penalty
Summary
A resident with a history of cerebral infarction, anxiety, and severe cognitive impairment was found to have a bed sheet tied across their abdomen and secured to the mattress, restricting movement. The resident was admitted with a high risk for falls and required assistance for transfers and personal hygiene, but was able to reposition independently in bed. Multiple unwitnessed falls from bed were documented in the weeks prior to the incident. Staff interviews revealed that several nursing assistants and a speech language pathologist observed the sheet tied across the resident's waist, and staff routinely removed and reapplied the sheet during care without knowledge of its intended purpose. Record review showed there was no physician's order, assessment, or documentation of medical symptoms justifying the use of a restraint, nor evidence of alternative interventions attempted prior to restraint use. The facility's policy defined such use of sheets as a physical restraint, and the Director of Nursing Services acknowledged the resident was physically restrained. The facility was unable to identify the staff member responsible for initiating the restraint, and written statements confirmed the practice of removing and reapplying the sheet during care.