Improper Use of Physical Restraint for Staff Convenience
Penalty
Summary
A deficiency occurred when a severely cognitively impaired resident with Alzheimer's Disease, who was dependent on staff for all activities of daily living and enrolled in hospice, was found with her shirt sleeves tied together, restricting her arm movement. This action was taken by a Certified Nursing Assistant (CNA) during care, reportedly to prevent the resident from scratching or pinching staff. The CNA, working without the required second staff member for assistance, tied the resident's sleeves together and then left the room to assist with another resident, forgetting to return and untie the sleeves. The resident was left unattended in this restrained state for an extended period. Interviews and record reviews revealed inconsistencies in staff accounts regarding who was present and involved in the incident. The CNAs involved provided conflicting statements about their roles and awareness of the restraint. There was no documentation of behaviors or incidents justifying the use of a restraint on the date in question, and the resident's care plan did not include individualized interventions for such behaviors prior to the incident. Additionally, the nurse on duty was not notified of any behavioral issues or the use of a restraint, and the restraint was only discovered by oncoming staff during shift change. Facility policy prohibits the use of physical restraints for staff convenience or discipline, defining a restraint as any method that restricts a resident's freedom of movement and cannot be easily removed by the resident. The investigation found that the restraint was used for staff convenience rather than as a last resort or with appropriate documentation and oversight. The resident, who was unable to communicate and was described as frail and contracted, experienced psychosocial harm as a result of being restrained in this manner.