Failure to Prevent Abuse and Use of Physical Restraint During Medication Administration
Penalty
Summary
Facility staff held a resident down to administer an intramuscular (IM) medication due to the resident's behaviors, which constituted a violation of the resident's right to be free from physical restraint. The staff's actions were not in accordance with the resident's care plan, as the behavioral interventions outlined in the care plan were not followed. Documentation indicated that staff attempted three interventions—offering food, assessing pain, and playing music—before administering the medication, but only the pain assessment was a care plan intervention, and there was no evidence that it resulted in an actual intervention such as administering pain medication. Additionally, offering food and music were not listed in the care plan as interventions. The facility's investigation substantiated that abuse occurred and found that staff interactions contributed to the escalation of the resident's behaviors. The resident's behaviors did not pose an immediate risk of harm to herself or others at the time of the incident. There was also no physician order authorizing staff to physically restrain the resident during medication administration. The incident was reported to the State Survey Agency, and the facility's investigation confirmed that the staff failed to follow established protocols and care plan interventions, resulting in the substantiated finding of abuse.