Inappropriate Use of Physical Restraints During Medication Administration
Penalty
Summary
Facility staff failed to ensure that a resident was free from the use of physical restraints not required to treat medical symptoms. The facility's policy requires that physical restraints only be used after a comprehensive assessment, as a last resort, and with a physician order and consent from the resident's legal representative. However, staff used physical force to administer oral psychotropic medications to a resident with severe cognitive impairment and a history of psychiatric disorders, including anxiety, depression, and psychosis. The resident had a court order for involuntary medication, and the care plan specified disguising medications in food or drink, but did not include the use of physical restraints for medication administration. On two occasions, staff members held the resident's arms and face to forcibly administer medications by mouth, despite the resident not being physically aggressive but attempting to push the medications away. One CNA held the resident's hands above his head and then at his sides, while another held the resident's face to open his mouth, and a nurse supervised the process. Staff justified their actions by citing the court order for medication, but there was no physician order for the use of physical restraints, nor was this intervention included in the care plan. The medication administration record did not document reasons for refusals or alternative interventions attempted. The incident was reported by a CNA who expressed concern about the use of force, and an internal investigation substantiated the allegation of inappropriate use of physical restraints. The facility's documentation and staff interviews confirmed that the use of physical force occurred during medication administration, in violation of facility policy and regulatory requirements. The resident's care plan and physician orders did not authorize the use of physical restraints for this purpose.