Unauthorized Use of Physical Restraints on Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical diagnoses, including traumatic brain injury and alcohol-induced mood disorder, was subjected to the use of physical restraints. The resident, who was non-ambulatory and dependent on staff for mobility and transfers, was identified as being at risk for falls and required to be within line of sight of staff at all times. Despite this, staff placed two dining room chairs behind the resident's wheelchair while he was seated at a dining room table in the common area, restricting his ability to move his wheelchair backward. Multiple staff members observed the chairs positioned behind the resident's wheelchair on several occasions, with some staff removing the chairs when they noticed them. Staff interviews revealed that the chairs were placed to prevent the resident from standing up or moving backward, as staff were unable to provide constant supervision. The resident was also pushed up to the table with his chest almost touching it, and the wheelchair was locked, further limiting his movement. Staff acknowledged that the chairs were used as a means to control the resident's mobility due to staffing constraints and the resident's tendency to attempt standing. Facility policy prohibits the use of physical restraints except for medical treatment and only after other alternatives have been tried unsuccessfully. The policy also defines physical restraint as any method that restricts a resident's freedom of movement and cannot be easily removed by the resident. The use of chairs to block the resident's wheelchair was not authorized, not medically indicated, and was implemented for staff convenience rather than the resident's safety or medical need, constituting a violation of the facility's restraint policy.