Resident Restrained with Bed Sheet Without Physician Order or Consent
Penalty
Summary
A certified nursing assistant (CNA) wrapped a bed sheet around a resident's waist and tied it behind the resident's wheelchair, preventing the resident from easily removing the material. This action was observed by the resident's representative, who found the resident in the dining room unable to move freely, with the CNA present and working on the computer. The resident reported feeling scared and called his son for help. The facility's policy and procedure (P&P) on the use of restraints specifies that restraints are only to be used for the safety and well-being of the resident, only after alternatives have been tried unsuccessfully, and only with a physician's order and consent. The P&P also defines a restraint as any device that the resident cannot remove in the same manner as applied, which restricts their ability to change position or place. Medical record review for the resident showed no documentation of a physician's order or any medical necessity for the use of physical restraints. The resident had a history of moderate cognitive impairment but was assessed as having the capacity to understand and make decisions. The CNA stated that the resident frequently got out of bed without assistance and was at risk of falling, and that the CNA needed to care for other residents. The CNA admitted to tying the resident to the wheelchair for safety reasons and acknowledged that this action was inappropriate and should have been reported to the charge nurse. Interviews with other staff confirmed the presence of the bed sheet tied around the resident in the wheelchair, though one licensed vocational nurse (LVN) did not check if the sheet was actually tied. The incident was reported to the charge nurse by both the resident's representative and the LVN. The director of nursing (DON) was informed and acknowledged the findings. There was no evidence that alternatives to restraint were attempted, nor was there documentation of required orders or consent for restraint use.