Failure to Protect Resident from Unauthorized Physical Restraint and Involuntary Seclusion
Penalty
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.