Unauthorized Use of Physical Restraint on Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) wrapped a linen sheet around a resident's legs and tied it to the bedframe, restricting the resident's movement. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was found with his legs immobilized by the sheet. Multiple staff members, including registered nurses and other CNAs, observed the resident in this state and confirmed that the sheet was tied tightly enough to prevent movement. The CNA responsible stated that the action was intended to prevent the resident from sliding out of bed, but acknowledged that this was not an approved or trained method for addressing such issues. The resident involved had a complex medical history, including type 2 diabetes, Alzheimer's disease, dementia, dysphagia, benign prostatic hyperplasia, and hyperlipidemia. The Minimum Data Set assessment indicated severe cognitive impairment and total dependence on staff for care. Nursing notes and interviews documented that the resident was typically active in bed, moving his legs frequently, and that the restraint was not authorized by a physician or included in the resident's care plan. The facility's investigation substantiated that the CNA used an unauthorized method to restrict the resident's movement, in violation of facility policy and without a physician's order. Facility policy explicitly prohibits the use of physical restraints, including tucking sheets so tightly that a resident cannot move, unless ordered by a physician and with proper consent. Staff interviews, including those with the Director of Nursing and Director of Staff Development, confirmed that the use of a sheet as a restraint was not standard practice and was considered a violation of resident rights and dignity. The incident was identified as a suspicion of involuntary restraint, and the CNA involved was suspended and subsequently resigned.