Inappropriate Use of Physical Restraint During Resident Care
Penalty
Summary
Facility staff failed to protect a resident with severe cognitive impairment, including diagnoses of unspecified dementia and Alzheimer's disease, from inappropriate use of physical restraint during care. According to interviews and record reviews, two CNAs attempted to assist the resident with toileting when the resident became combative, swinging arms and attempting to strike staff. In response, one CNA held the resident's hands across the chest to prevent hitting, which is considered a form of physical restraint. The facility's policy prohibits rough handling and requires staff to manage behaviors in a way that prevents injury, pain, or distress. Documentation revealed that following the incident, the resident was found to have a skin tear on the right lower abdomen and a large bruise on the right hand. Staff interviews confirmed that the restraint was applied during care, and the Assistant Director of Nursing acknowledged that staff should have stepped away and notified nursing staff rather than continuing care during combative behavior. The Administrator confirmed that restraining residents during care is not acceptable per facility expectations and policy.