Failure to Protect Resident from Unauthorized Physical Restraint and Involuntary Seclusion
Summary
Facility staff failed to protect a resident's right to be free from physical restraints not required for medical treatment. On the day of the incident, the resident, who had diagnoses including major depressive disorder, anxiety disorder, unspecified dementia, and Alzheimer's disease, exhibited behaviors such as wandering, taking items from other residents' rooms, and becoming agitated when items were removed from his possession. The situation escalated when the resident became physically aggressive, swinging a call light cord and striking staff with a bedside table. In response, four staff members, including nursing and non-nursing personnel, physically restrained the resident by grabbing his arms and legs, dragging him across the floor, and carrying him by his extremities to his room without supporting his back or midsection. Once in the room, staff held the door closed, preventing the resident from leaving. The resident's care plan included interventions for aggressive behavior, such as removing him from situations, using calm communication, and providing diversions, but did not authorize the use of physical restraints. There was no physician order for restraints, and the only relevant medication order was a one-time administration of Haldol after the incident. Staff interviews revealed that the decision to physically restrain and seclude the resident was made collectively for staff convenience and safety, rather than as a last resort after all other interventions had failed. The Director of Nursing and Administrator were not fully informed of the severity of the incident until after reviewing video footage, and both expressed that staff actions did not align with facility expectations or policies. Facility policies reviewed by surveyors clearly prohibited the use of physical restraints for discipline or convenience and required thorough assessment, physician orders, and consent for any restraint use. The policies also defined physical and mental abuse, including unreasonable confinement and involuntary seclusion. The staff's actions in restraining and secluding the resident were not in accordance with these policies, and there was a lack of immediate notification to the resident's power of attorney and primary physician regarding the incident. The deficiency was identified as Immediate Jeopardy due to the failure to protect the resident's rights and the risk of physical and psychological harm.
Removal Plan
- Staff members LVN A, RN and NA were immediately suspended by the administrator. All three staff members remain suspended.
- Resident #1 had a head-to-toe assessment completed by the charge nurse. No further injuries were noted. The skin tears to resident #1's finger and upper arm are being treated according to physician orders.
- Trauma informed care assessments were completed by the DON/ADON and Social Worker on all residents including resident #1 and documented in the charts. No new findings were assessed. Resident #1 was at his baseline. No behaviors or emotional distress were noted.
- The Administrator, DON, ADON completed rounds on every resident in the facility to ensure that no additional unauthorized restraints or involuntary seclusion were in use on any residents.
- Safe surveys were completed for all residents who are able to be interviewed by the Administrator, DON, ADON and Social Worker. No additional unauthorized restraints or signs of involuntary seclusion were noted.
- Head-to-toe skin assessments were completed on all residents by the DON/ADON and nurses. No signs of abuse or new injuries were discovered.
- Staff interviews were conducted by the Administrator and DON to determine if any restraints or involuntary seclusion have been observed or used on any other residents in the facility. No additional findings were noted.
- The medical director was notified of the immediate jeopardy by the Administrator.
- An ADHOC QAPI meeting was completed with the Administrator, DON, ADON, and Medical Director to discuss the immediate jeopardy and plan of removal.
- The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following topics and policies: Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement; Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent; Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement; Trauma informed Care to include the use of unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma or re-traumatization to a resident; Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily.
- The following in-services were initiated by Regional Compliance Nurse, DON, ADON for all staff. Any staff member not present or in-serviced will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment. Topics: Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement; Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent; Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement; Trauma informed Care to include unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma; Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Body pillows were used as restraints for three residents with significant cognitive and mobility impairments. Staff placed body pillows under sheets or tightly against the bed to keep residents in bed or prevent them from removing the pillows, and an NA stated this was done so a resident would not try to get out of or roll out of bed. The LPN and DON stated that placing body pillows this way made them a restraint.
Failure to assess whether a mattress bolster was a restraint for a resident with dementia, anemia, and HTN. The resident’s care plan included bolsters to bed for fall risk, and staff observed the resident in bed with bilateral raised mattress edges, but the record had no assessments or ongoing evaluations of bolster use. A UM confirmed the facility did not assess the resident’s functional status to determine whether the bolster was a restraint.
Improper Use of Roll Bolster as a Physical Restraint: A resident with dementia and severe cognitive impairment was observed with a Roll Bolster secured along the side of the bed, limiting the ability to sit up, stand, or get out of bed independently. Staff stated it was being used to prevent the resident from rolling over and exiting the bed, but there was no physician order, no documented use of alternative measures, no informed consent from the responsible party, and no care plan for the device. The facility policy identified such a device as a physical restraint when it restricts movement.
A resident with epilepsy and profound intellectual disabilities remained in a padded wheelchair with a lap belt and helmet, but staff did not release the belt during supervised care and meals. The DON stated the belt should be released when supervised and at least every two hours, yet the restraint reduction assessment was copied from an older date and staff said they had not tried to reduce the restraint because the resident’s epilepsy had not changed.
Failure to Complete Quarterly Restraint Reassessments: A resident with quadriplegia, muscle weakness, and impaired mobility used a wheelchair seat belt and lap tray, and observations showed both devices in place while the resident was in a power wheelchair. Although the care plan addressed the seat belt and noted the resident could independently lock and release it, the EMR showed the last restraint quarterly assessment was completed months earlier, with no later reassessment documented. RN and DON interviews confirmed the quarterly reassessment was expected but had not been completed.
A resident with intact cognition and behavioral symptoms including paranoia, hallucinations, and attempts to leave the building became highly agitated, pulled fire alarms, entered other residents’ rooms, and handled a fire extinguisher. Video and staff statements showed an LPN/CNA physically held the resident by the wrist, waist, and back while escorting the resident to the room, despite no order authorizing restraint and the resident not consenting to the contact.
Body pillows used as restraints
Penalty
Summary
The facility failed to ensure body pillows used as positioning devices were not implemented as physical restraints for 3 of 3 residents reviewed for restraints. R5 had diagnoses including a right femur fracture, osteoarthritis, dementia, osteoporosis, and a history of falling. After a witnessed fall, staff placed a body pillow under the sheets to prevent further self-ambulation, and the fall care plan was revised to include the body pillow under the sheets. R5 later had another incident in which she was found on the floor at the foot of the bed after family had placed her in bed without staff assistance. R11 had diagnoses of hemiplegia and hemiparesis affecting the left side and dementia. Her fall review identified her as at risk for falls due to scheduled narcotics, psychotropics, bowel and bladder incontinence, and being alert but unaware of mobility limitations. Her care plan included a body pillow for repositioning when in bed. During observation, staff placed a body pillow between R11 and the side of the bed underneath the sheet and tucked it securely into place, and the NA stated the body pillow was used to keep R11 in bed. R10 had diagnoses of hemiplegia and hemiparesis following cerebral infarction. Her MDS identified moderate cognitive impairment, daily physical and verbal behaviors, daily rejection of care, and need for substantial to maximum assistance with bed mobility and transfers. Her care plan included body pillows to outline the mattress parameter. During observation, a body pillow was tucked under the mattress sheet on the side of the bed, and the NA stated it was placed tightly so R10 would not remove it and so he would not attempt to get out of or roll out of bed. The nurse manager and DON stated body pillows should never be placed under the sheets to keep residents from getting out of bed and that doing so made the body pillow a restraint.
Failure to Assess Mattress Bolster as a Possible Restraint
Penalty
Summary
The facility failed to assess the functional status of Resident R23 to determine whether the use of a bolster on the mattress was a restraint. Facility policy defined physical restraints as any method or device attached to or adjacent to the resident’s body that the individual cannot remove easily and that restricts freedom of movement or normal access to the body. Resident R23’s record showed admission to the facility, diagnoses of high blood pressure, dementia, and anemia, and a physician order for a bolster mattress to bed dated 12/23/24. Resident R23’s care plan identified the resident as high risk for falls related to confusion, psychoactive drug use, a history of a fall at home with left hip fracture, and poor balance and safety awareness, with interventions including bolsters to bed when in bed. During observation on 6/23/26 at 9:47 a.m., Resident R23 was lying in bed with a mattress that had bilateral raised edges on the top and bottom portions. The clinical record did not identify any assessments or ongoing evaluations for the use of bolsters on the resident’s mattress, and a Unit Manager confirmed on 6/26/26 at 9:26 a.m. that the facility failed to assess whether the bolster was a restraint for the resident.
Improper Use of Roll Bolster as a Physical Restraint
Penalty
Summary
Resident 67 was observed with a Roll Bolster secured to the left side of the bed, extending from the shoulder to the lower extremities and restricting the resident’s ability to sit up, stand, or reposition independently. The resident was admitted with diagnoses including dementia, fracture of the left humerus, and muscle wasting, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated severely impaired cognitive skills and moderate assistance was needed with ADLs. The facility used the Roll Bolster to prevent the resident from getting out of bed and rolling over, but the record review found no physician order for the device, no documented evidence that alternative measures were used before it was placed, and no informed consent from the responsible party. During interviews, staff stated the bolster was being used to keep the resident from getting out of bed, and the DON confirmed there was no documented physician order, no informed consent, and no care plan developed for the use of the Roll Bolster. The facility’s policy stated that any mechanical device attached to or adjacent to a resident’s body that restricts freedom of movement is a physical restraint and requires a physician’s order, informed consent, documentation, care planning, ongoing monitoring, and periodic reevaluation. The RDCO stated that if the bolster inhibits the resident’s ability to get out of bed, it is considered a restraint, and the DON stated staff should have obtained a physician’s order, consent, and notified the resident or responsible party before placing any restraint.
Failure to Reduce and Release Wheelchair Lap Belt
Penalty
Summary
The facility failed to attempt a reduction of a resident’s restraint and failed to release the restraint when the resident was supervised. Resident R3 had diagnoses including epilepsy, profound intellectual disabilities, dysphagia, osteoporosis, and acute kidney failure, and was using a lap belt while seated in a padded wheelchair along with a protective helmet. During observation at lunch, R3 remained in the wheelchair with the seatbelt in place while staff removed the helmet and assisted with feeding; the seatbelt was not released during the supervised meal. Staff stated the helmet is removed at lunch and that the new padded wheelchair was helping with positioning, and they reported that R3 rarely scoots anymore and only needed repositioning once earlier. Record review showed the restraint reduction assessment was dated 10/7/25 and stated R3 continued to require the lap belt because of poor trunk control, spastic involuntary movements, and seizures, with the belt released under direct supervision and by the resident’s mother. The progress notes from 1/1/26 through 6/23/26 did not show any falls from the padded reclining wheelchair. The DON stated the seatbelt should be released at least every two hours and when R3 is supervised, but also stated the assessment had been copied and pasted and that R3’s epilepsy diagnosis had not changed, so they had not tried to reduce the restraint. The care plan stated R3 needed the lap belt and helmet when left unattended in the wheelchair, and the facility policy required the need for a restraint to be re-evaluated at least quarterly with efforts made to eliminate continued use.
Failure to Complete Quarterly Restraint Reassessments
Penalty
Summary
The facility failed to ensure ongoing assessment and evaluation of physical restraints for a resident who used a wheelchair lap tray and seat belt. The resident had intact cognition and diagnoses including quadriplegia, muscle weakness, lack of coordination, and abnormalities of gait and mobility. The quarterly MDS dated [DATE] identified that the resident did not use restraints, yet observations on 6/22/26 and 6/25/26 showed the resident seated and propelling in a power wheelchair with a secured seat belt and lap tray in place. The resident’s care plan dated 5/11/26 identified the seat belt use, noted the resident could lock and release it independently, and stated the resident had been educated on risks versus benefits and signed consent for use. The Physical Restraint Quarterly Assessment history showed the most recent assessment was completed on 2/17/26, and the EMR lacked evidence of any additional quarterly restraint assessments after that date. RN-A stated the nurse manager was responsible for reassessing continued need and ability to use the devices. The RNCM confirmed the assessment should have been completed after 2/17/26 and stated it had not triggered in the EMR system. The DON also confirmed another assessment should have been completed after 2/17/26 and stated quarterly assessments were expected to determine continued need, independent removal ability, and whether alternative interventions were needed.
Physical restraint used during behavioral episode
Penalty
Summary
The facility failed to keep a resident free from physical restraints during a behavioral episode. Resident #1 had a BIMS score of 13, indicating intact cognition, and diagnoses that included hypertension, arthritis, and COPD. The resident’s care plan documented paranoia, negative statements, medication and care refusals, attempts to leave the building, calling the police, hallucinations, and delusions, with interventions focused on reassurance, leaving and returning later, calm communication, diversion, and protecting other residents by removing the resident to another location. During the overnight incident, Resident #1 pulled fire alarms, entered other residents’ rooms, screamed for help, ripped a telephone off the wall, destroyed it, and grabbed a fire extinguisher and aimed it at residents and staff. Staff reports and video evidence showed that Staff B approached Resident #1 from behind, placed an arm around the resident’s back, held the resident’s wrist, and secured the resident’s waist while escorting the resident back to the room. The report states that Resident #1 did not consent to the physical contact and could not disengage, and that the hold continued as the resident was guided down the hallway and into the room. Staff statements described the contact as an attempt to prevent a fall or calm the resident, but the facility’s own restraint-free policy defined physical restraint to include holding down a resident in response to behavioral symptoms or during care when the resident resists or refuses care. The record review found no order authorizing staff to physically restrain Resident #1. Interviews with staff and the DON confirmed that the facility did not consider physical restraints acceptable practice, yet the documented actions during the incident included holding the resident by the wrist, waist, and back while the resident resisted, lowered to the floor, and refused to stand.
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