Resident Placed in Unauthorized Head Lock During Behavioral Incident
Penalty
Summary
A deficiency occurred when a resident's right to be free from physical abuse was violated after a staff member, Floor Tech N, placed the resident in a head lock during an altercation. The incident began when the resident, who had diagnoses including depression and schizophrenia and was noted to have intact cognition, became physically aggressive. The resident first engaged in a resident-to-resident altercation during a smoke break, after which he was placed on 1:1 supervision. While being escorted back inside by Floor Tech N, the resident attacked a CNA, who was also Floor Tech N's family member, by hitting and pulling hair. In response, Floor Tech N intervened by grabbing the resident from behind and placing him in a head lock, which is not an approved restraint technique according to the facility's policies and CPI training protocols. Multiple staff interviews confirmed that Floor Tech N used a head lock to restrain the resident, and that the proper CPI technique was not followed. The resident reported being choked and stated that Floor Tech N threatened him verbally. Other staff present during the incident indicated that there was confusion and fear among staff, with some not intervening as expected. The Administrator and Staffing Coordinator both noted that Floor Tech N did not de-escalate the situation as directed and did not use the correct CPI-approved restraint methods. The Administrator was also physically attacked by the resident after the restraint was released, and staff struggled to manage the situation safely. The facility's policies require that all residents be protected from abuse, including improper use of physical force or restraint, and that staff use only approved de-escalation and intervention techniques. Despite having completed CPI training, Floor Tech N did not adhere to these protocols, resulting in the use of an unauthorized physical restraint. The incident was further complicated by the involvement of Floor Tech N's family member and the lack of coordinated staff response, which contributed to the violation of the resident's rights and the facility's failure to prevent abuse.