Resident Restrained for Haldol Injection During Behavioral Episode
Penalty
Summary
Staff failed to ensure a resident was free from physical restraints when three staff members held down a resident with severe dementia and agitation in order to administer an intramuscular injection of Haldol, an antipsychotic medication. The resident, who had a history of behavioral issues including anger, resistance to care, and exit-seeking, became verbally and physically abusive after repeatedly expressing a desire to leave the facility. Despite the care plan indicating the need to anticipate and meet the resident's needs and to monitor for medication side effects, staff proceeded to restrain the resident during the administration of the medication after he refused it and became aggressive, including spitting at staff. Documentation in the nursing progress notes initially described the restraint and was later struck through after the Unit Manager advised that holding a resident down for medication was not appropriate. Interviews with staff confirmed that the resident was physically restrained during the injection, and that alternative interventions, such as redirection or bargaining, were not consistently attempted prior to the use of restraint. The Director of Nursing and Unit Manager both acknowledged that physically restraining a resident for medication administration was not acceptable practice.