Improper Use of Physical Restraints Without Physician Order
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and a history of dementia and failure to thrive was found with pillows placed on both sides of their body, restricting their movement. The resident was dependent on staff for activities of daily living and lacked the capacity to make decisions. During an observation, a CNA admitted to placing the pillows during breakfast and forgetting to remove them, acknowledging awareness that such use of pillows could constitute a restraint. Further interviews revealed that the LVN had previously instructed the CNA not to use pillows in this manner to restrict the resident's movement, and confirmed that there were no physician orders for restraints for this resident. The DON also stated that pillows placed in a way that restricts movement and cannot be removed by the resident are considered restraints. Review of facility policy confirmed that restraints should only be used with a physician's order and not for staff convenience or fall prevention, and that any material restricting movement and not easily removed by the resident is considered a physical restraint.
Plan Of Correction
C 1130-Nursing Service - Restraints and Postural Support A) IMMEDIATE CORRECTIVE ACTION: 7. On 10/06/2025, CNA #2 immediately removed patient 4's bilateral pillows. RN Supervisor immediately assessed patient 4 for any change of condition (COC) or adverse effects that may have been caused by the bilateral pillows. No COC noted. MD and RP were notified. 8. On 10/06/2025, DSD completed a one-on-one in-service with CNA 2 on facility's restraint-free environment policies and procedures. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: 4. On 10/6/2025, upon identification of deficient practice, DON, ADON, and DSD immediately rounded the facility to ensure that no additional residents have pillows by their sides that may be used as restraints. No further residents were identified to be affected by the deficient practice. 5. The Medical Records Department continues to do daily audits on Change of Condition that reflects any incident requiring the use of restraints. At this time, no resident was identified and observed to have any form of restraint at all. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: 3. On 10/28/2025, DON completed an in-service for all nursing staff on a P/P: "Restraint Usage." The discussion was followed by question-and-answer evaluation with all participants. On 10/30/2025, Social Services Director and DSD completed additional in-services on a "Restraint Free Environment." The discussion was followed by question-and-answer evaluation. 4. On 10/29/2025, Administrator updated the form "Resident Centered Care Room Rounds Report" to include "Does resident have any objects that may be a restraint?" question on daily rounds to be completed daily by assigned ambassadors and/or Manager on Duty (MOD). Any noted deviations will be corrected immediately, and surveillance tools will be submitted to the DON and/or Designee for monitoring. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: Time, no resident was identified and observed to have any form of restraint at all.