Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by regulation. On the evening of the incident, two CNAs were observed tying a sheet around a resident's waist and securing it to the back of a chair, while an LPN was present in the room. The incident was witnessed by another CNA, who reported it to the lead CNA, and subsequently to facility administration. The resident involved had severe cognitive impairment, with a diagnosis of dementia and anxiety, and had a history of agitation and striking at staff, but there was no physician order or care plan in place for the use of physical restraints for this resident. Facility documentation, including incident reports and witness statements, confirmed that the staff involved had knowledge of the facility's restraint policies, which prohibit the use of physical restraints for staff convenience and require a physician's written order for any restraint use. Despite this, the staff proceeded to restrain the resident without proper authorization or documentation. The facility's investigation included review of personnel files, interviews with involved staff, and review of relevant policies, all of which indicated that the restraint was not care planned or medically authorized. The incident was reported to the appropriate authorities, and the facility's internal investigation found that the staff involved had violated facility policy regarding restraint use. The resident was assessed following the incident, with no negative outcomes documented. The deficiency was identified based on observations, interviews, and review of facility records, which demonstrated a failure to protect the resident's right to be free from physical restraints except as authorized for medical treatment.