Resident Found with Restrictive Clothing Used as Physical Restraint
Penalty
Summary
A deficiency occurred when a resident was found with the sleeves of their long-sleeve shirt tied together at the wrists, restricting the use of their hands and limiting freedom of movement. This action constituted the use of a physical restraint, as defined by the facility's own policy, which prohibits restraints unless necessary to treat a specific medical symptom and only after less restrictive interventions have failed. There was no documentation or physician order for the use of any restraint for this resident, nor was restraint use addressed in the resident's care plan. The resident involved had severe cognitive impairment, was rarely or never understood, and was totally dependent on staff for all activities of daily living. The resident had a history of non-traumatic brain dysfunction, hemiplegia, malnutrition, and anxiety disorder, and exhibited behavioral symptoms such as agitation, resistance to care, and repetitive movements like rubbing the scalp. Staff interviews confirmed that the resident could not have tied the sleeves themselves and that the knot was intentional, not accidental. The resident was unable to communicate what had happened and did not appear to be in distress at the time of discovery. Multiple staff, including CNAs and LPNs, reported that they were unaware of how or when the sleeves were tied, and no one took responsibility for the action. The facility's leadership, including the Interim Administrator and DON, acknowledged that it was never determined who tied the resident's sleeves. The care plan did not include any interventions involving restraints, nor did it address the resident's repetitive behaviors. The incident was identified through observation, interview, and record review, confirming a failure to protect the resident's right to be free from physical restraints.