Resident Restrained with Trash Bags on Wheelchair Wheels
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) physically restrained a male resident with severe cognitive impairment, hemiplegia, and a history of falls by tying trash bags around the wheels of his wheelchair. This action was taken to restrict the resident's independent mobility after he was observed roaming the halls, entering other residents' rooms, and taking items from the nurse's station. The restraint was not ordered for medical treatment, was not documented in the care plan, and was not the least restrictive intervention. Multiple staff members observed the resident unable to move his wheelchair, appearing distressed and agitated, and attempting to reach for items while restrained. The incident was witnessed by a licensed vocational nurse (LVN), who intervened by cutting the trash bags off the wheelchair and reported the event to facility leadership. Other staff members also became aware of the restraint, with some expressing concern that it constituted abuse and should have been reported immediately. The CNA involved admitted to placing the trash bags on the wheelchair wheels to slow the resident down, acknowledging prior training on restraints and abuse, but did not perceive his actions as a restriction at the time. Facility records and staff interviews confirmed that the resident's care plan did not include the use of restraints, and the facility's policy promoted restraint-free care. The resident's primary mode of mobility was his wheelchair, and the restraint directly impeded his ability to move freely. The event was not immediately reported to the state, and there was a lack of timely notification to the facility administrator. The deficiency was identified based on staff interviews, resident records, and review of facility policies, which all indicated that the use of physical restraints in this manner was not permitted and violated the resident's right to dignity and freedom from unnecessary restraint.