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F0600
G

Resident Subjected to Excessive Physical Force During Alcohol Confiscation

Toledo, Ohio Survey Completed on 12-01-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with a history of alcohol dependence, anxiety, depression, and other medical conditions was subjected to excessive physical force by a staff member. The resident, who was moderately cognitively impaired and independently mobile in a wheelchair, was found drinking alcohol in the designated smoking area without a physician's order. When approached by staff, the resident became agitated and was accused of threatening staff, but video surveillance later showed that a Licensed Practical Nurse (LPN) used physical force to search the resident and confiscate alcohol, including pulling on the resident's coat and arms multiple times. The incident escalated when the LPN, after being instructed by another nurse to confiscate the alcohol, repeatedly reached into the resident's coat and physically restrained the resident's arm. The situation further deteriorated when the LPN struck the resident's arm multiple times after the resident pointed a finger at her. Other staff present intervened by removing a cigarette from the resident's hand, citing safety concerns. The resident subsequently reported feeling unsafe, fearful, and experiencing mental anguish as a result of the altercation. The facility's investigation confirmed the events as seen on video and through staff and resident interviews. The LPN involved had received prior training on abuse prevention but nonetheless engaged in actions that resulted in mental harm and a sense of insecurity for the resident. The incident was reported to the facility administration and state agency, and the resident was placed on one-to-one observation due to expressed feelings of depression and thoughts of self-harm following the event.

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