Failure to Ensure Resident Freedom from Physical Restraint During Medication Administration
Penalty
Summary
Nursing staff failed to ensure that a resident was free from physical restraint, as required, when they physically restrained her for medication administration on three separate occasions. The resident, a female with severe cognitive impairment, schizophrenia, anxiety disorder, and psychosis, was known to reject care daily and had a care plan addressing her refusal of care and risk for harm. However, the care plan did not include any interventions or assessments related to the use of physical restraint or therapeutic holds for medication administration. On the dates in question, staff physically restrained the resident by having four employees hold her limbs while an injection was administered. This action was taken after the resident refused medication and became agitated, with staff and the responsible party (RP) providing verbal consent for the restraint. The facility did not have a written physician's order for the restraint at the time, nor was there documentation of an assessment to justify the use of restraint. Additionally, staff involved in the restraint had not received training or practiced the technique for performing a therapeutic hold. Interviews with facility leadership and staff confirmed that the use of restraint was not care planned, not supported by a written order, and not preceded by an assessment. The facility's policy required a written order and care plan inclusion for restraint use, but these steps were not followed. The medication administration records were also found to be incomplete or inaccurate for the relevant dates. The lack of proper documentation, assessment, and staff training contributed to the deficient practice of restraining the resident without meeting regulatory requirements.