Failure to Prevent Unnecessary Restraint of a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary restraint. One resident, who had diagnoses including metabolic encephalopathy, gait and mobility abnormalities, and anxiety disorder, and who was assessed as having severely impaired cognition and requiring assistance with daily activities, was reportedly tied to a wheelchair with a white sheet. Interviews with staff and another resident confirmed that residents, including this individual, were observed tied to wheelchairs or Geri chairs, often covered with blankets, and unable to move freely. Staff acknowledged that using a sheet to tie a resident to a wheelchair constitutes a restraint if the resident cannot untie themselves and exit the chair independently. There were no physician orders for restraints in the resident's medical record, and the facility's policy explicitly states that residents have the right to be free from physical restraints used for discipline or staff convenience. Despite this policy, multiple interviews indicated that the use of sheets to restrain residents occurred, particularly in the early morning hours. The Director of Nursing stated that the facility does not use restraints, but this was contradicted by staff and resident interviews.