Failure to Report Alleged Abuse Involving Physical Restraint and Forced Medication
Penalty
Summary
The facility failed to report an allegation of abuse to the state agency after a resident with severe cognitive impairment, multiple diagnoses including dementia, and a care plan indicating high risk for exploitation was physically restrained and administered medication against her wishes. Documentation and staff interviews revealed that the resident, who had a history of calling out and refusing medications, was held down by staff at the direction of an RN while being given pain medication, despite her verbal refusal and attempts to turn her head away. The resident expressed distress, stating she was tired of being tied down, and staff observed the RN laughing at her while she was upset. The Director of Nursing (DON) was informed of the incident by staff who were upset about the manner in which the medication was administered. The DON acknowledged that holding a resident's hands down to administer medication constituted a restraint but did not report the incident to the state agency, as the on-call nurse believed there was no malicious intent. This inaction was contrary to the facility's Abuse Prevention Plan, which requires immediate reporting of suspected abuse or maltreatment.