Failure to Prevent Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as required by its policy and federal regulations. The policy defined a physical restraint as any device or material that restricts a resident's freedom of movement and cannot be easily removed by the resident. The incident involved a resident with reduced mobility, dementia, and anxiety, who was dependent on staff for personal hygiene and required substantial assistance with bed mobility and transfers. There was no documentation or physician order for the use of restraints for this resident. On the day of the incident, video surveillance showed a CNA wrapping a sheet around the resident's lower legs while she was seated in a geri-chair, then covering her legs with a blanket and tucking it under her legs. The CNA and other staff members later described this action as a way to prevent the resident from moving her legs, kicking off her blanket, or potentially falling. Multiple witness statements and interviews confirmed that the CNA had wrapped or tied the resident's legs to the chair, and that this was done to manage the resident's restlessness and prevent her from throwing her blanket on the floor. The CNA stated that this practice was common among staff, especially when they were short-staffed, and did not consider it a restraint because the resident could still move her legs to some extent. Despite the CNA's and some staff's belief that the resident was not fully restrained, the video and witness accounts indicated that the resident's ability to move her legs independently was restricted. The facility's own Human Resources Manager and Administrator acknowledged that the sheet was wrapped and tucked in a manner that limited the resident's movement, and the Quality and Regulation Manager stated that such wrapping would be considered a restraint if it prevented independent movement of the legs. There was no evidence that the use of the sheet as a restraint was medically necessary or properly documented, and the action was taken for staff convenience rather than to address a medical symptom.