Failure to Prevent Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to ensure that residents were not physically restrained, as evidenced by the handling of a resident with a history of Type II Diabetes, morbid obesity, bipolar disorder, and depression. The resident exhibited aggressive behaviors, including yelling, swinging fists at staff, and attempting to enter other residents' rooms. Despite multiple attempts by staff to verbally de-escalate the situation and meet the resident's needs, these interventions were unsuccessful, and law enforcement was contacted on two occasions due to the resident's escalating aggression. During one of these incidents, staff used a bath sheet to physically restrain the resident in his wheelchair. The sheet was placed across the resident's torso and chest and held behind him by an LPN, preventing the resident from striking staff or other residents. This action was confirmed through interviews with staff members, including the LPN who held the sheet and a CNA who witnessed the event. The restraint was not documented in the resident's medical record, and there were no physician orders authorizing the use of a restraint. Facility policy defines a restraint as any device that a resident cannot remove in the same manner as it was applied and that restricts the resident's ability to change position or place. The use of the bath sheet in this manner met the facility's definition of a restraint. The internal investigation confirmed the use of the sheet as a restraint, although staff statements and progress notes did not consistently document this intervention.