Failure to Follow Restraint Policy for Justice-Involved Residents
Penalty
Summary
The facility failed to follow its own policy and procedure regarding the use of physical restraints for three justice-involved residents who were under the care of law enforcement and admitted to the facility in metal shackles. These residents were observed restrained with metal shackles on their ankles and, in some cases, wrists, which were attached to the bed frame or side rails. The shackles were only removed when the residents needed to use the restroom, shower, or participate in physical therapy, and the removal was performed by correctional officers, not facility staff. Facility staff, including CNAs and nurses, did not conduct regular assessments of the residents' skin integrity or document the use of restraints, as required by the facility's policy. Interviews with staff revealed that the facility considered itself a 'no-restraint' facility and did not classify the shackles as restraints, despite their definition in the facility's own policy. Staff were not trained in the use of restraints, did not perform or document pre-restraining assessments, and did not obtain physician orders for the use of restraints. There was no care plan in place for the use of restraints, and the use of shackles was not coded on the Minimum Data Set (MDS). Nursing progress notes did not include documentation of the placement or removal of restraints, nor were there assessments of skin integrity related to the use of shackles. The residents affected had significant medical conditions, including hemiplegia, hemiparesis, heart failure, hypotension, peripheral autonomic neuropathy, acute kidney failure, hand fracture, cellulitis, neuropathy, and hypertension. Despite these conditions, the facility did not provide the required monitoring or documentation for the use of restraints. The responsibility for monitoring and managing the restraints was placed solely on the correctional officers, and the residents did not participate in activities outside their rooms except for showers and physical therapy. The facility's failure to adhere to its own restraint policy and federal regulations resulted in a deficiency related to the respectful and dignified treatment of these residents.
Removal Plan
- Residents identified as affected by the deficient practice involving the use of physical restraints were discharged in coordination with the Federal Correctional Complex (FCC) Victorville and attending physician and transferred to [NAME] Valley Global Medical Center.
- The attending physician declined to issue orders for the continued use of restraints.
- Residents affected by the deficient practice will be discharged in coordination with FCC as follows: Room # 9A Resident 1 to [Name of the hospital], Room # 9C Resident 2 to [Name of the hospital], Room # 16C Resident 3 to [Name of the hospital].
- A comprehensive review of records for 107 residents was completed. In addition, direct observations were conducted across all shifts by charge nurses and Registered Nurses. Alert residents were interviewed by staff. No additional residents were found to be affected by the deficient practice.
- Ongoing in-service training was provided by Director of Staff Development with an emphasis on the distinction between medical and correctional restraints.
- Resident's requiring physical restraints will be observed for 72 hours, during which non-pharmacological interventions will be attempted in collaboration with Activities, Social Services, Nursing, and Rehab.
- Physicians and family members will be notified, and nursing staff will follow up on all physician orders.
- Social Services, in coordination with the interdisciplinary team (IDT), will provide information regarding the resident's behavior and the effectiveness of the treatment plan to the resident and, as appropriate, to the family or responsible party.
- Licensed nurses will conduct weekly skin integrity checks and document daily progress notes. Any concerns will be escalated to the Primary Care Provider (PCP) and family.
- Residents will be repositioned per facility protocol.
- Monthly psychosocial-emotional assessments will be conducted by Social Services, with documentation of observations, interviews, and reviews involving residents, families, and staff.
- Recapitulation of findings will be presented and reported by the Director of Nursing (DON) or designee to the Quality Assessment and Assurance Committee on a monthly basis for three months, or until 100% compliance has been sustained. The Committee will review the findings and take action as indicated.
- The facility will not admit justice-involved individuals until it has confirmed substantial compliance with all applicable statutes and regulations governing the care of justice-involved individuals.