Failure to Protect Resident from Abuse and Neglect through Unauthorized Restraint and Seclusion
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse and neglect when four staff members, including licensed nurses, a nursing assistant, and a laundry staff member, physically restrained and forcibly carried a resident by his extremities, dragging him on the floor to his room. Once inside, the staff placed the resident in his room and held the door closed, preventing him from leaving. This action was taken in response to the resident exhibiting aggressive behaviors, including attempting to strike staff and other residents, and swinging a call light cord. The staff did not attempt de-escalation techniques or remove other residents from the area, and instead chose to physically restrain and seclude the resident without a physician's order or proper assessment. The resident involved had a history of major depressive disorder, anxiety disorder, and unspecified dementia with severe cognitive impairment, as indicated by a BIMS score of 5. He was admitted to a secure unit due to a history of elopement and was also under hospice care. Prior to the incident, the resident had documented skin tears on his fingers and upper arm, and his care plan included interventions for behavioral issues, such as positive interaction, de-escalation, and involving family when confusion or combativeness increased. However, the care plan did not include the use of physical restraints or involuntary seclusion, and there was no physician order for such interventions at the time of the incident. Interviews and video evidence confirmed that staff did not follow established protocols for managing aggressive behaviors, such as using de-escalation techniques or ensuring the safety of other residents by removing them from the area. Instead, staff physically restrained the resident, carried him by his arms and legs, and held him in his room against his will. The Director of Nursing and Administrator were not fully informed of the severity of the incident until after reviewing video footage. The resident's power of attorney was also not promptly notified of the incident or the use of restraints and medication. The facility's actions constituted abuse and neglect, as defined by their own policies and federal regulations.