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F0604
D

Resident Restrained During Oral Care by Respiratory Therapist

Riverton, Utah Survey Completed on 04-30-2025

Penalty

Fine: $66,079
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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 deficiency occurred when a respiratory therapist (RT) physically restrained a resident during oral care by placing the resident's hands between her knees, restricting the resident's ability to move. The resident, who had severely impaired cognitive skills and was dependent on staff for daily care, became visibly upset and attempted to cover her face during the procedure. Despite the resident's distress and an offer of assistance from a registered nurse (RN), the RT declined help and continued the care while restraining the resident's hands. The incident was witnessed by an RN, who observed that the resident appeared to be in distress and unable to move her hands away. The resident's care plan indicated a history of combative behavior during care and prescribed interventions such as listening to the resident's preferences and using medications for agitation. There were no medical orders for restraints in the resident's records. Interviews with other staff confirmed that the standard practice was to use distraction or a second staff member if a resident was resistant, and not to restrain residents. The facility's policy defined a physical restraint as any method that restricts a resident's freedom of movement, which was consistent with the actions observed during the incident.

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