Improper Use of Hand Restraints by Untrained Staff Resulting in Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff received facility-specific restraint and abuse prevention training prior to providing resident care, resulting in the use of an unauthorized physical restraint on a resident. A staff member (Staff D) observed Resident #3, who had an ostomy and a surgical wound on the hip, becoming very anxious and agitated and digging at her surgical site and stoma to the point of causing bleeding. After administering PRN lorazepam and morphine and reassessing the resident 15–20 minutes later, Staff D noted that the resident continued to dig at her surgical site and stoma and became further concerned for her safety. At that point, Staff D attempted to protect the resident by wrapping washcloths and pillowcases around the resident’s hands to prevent her from continuing to dig at her ostomy site. One hand was already wrapped when another staff member (Staff E) entered the room and observed Staff D attempting to wrap the resident’s other hand. Staff E immediately stopped the process, informed Staff D that what he was doing could be considered a restraint and was not allowed in the LTC setting, and removed the washcloths from the resident’s hand. During this episode, the resident bit at her wrapped left hand and cracked one of her teeth. The facility’s investigation confirmed that this was an incident in which a well-intentioned staff member, attempting to protect the resident from self-harm, implemented an intervention that was not appropriate for the setting and constituted a physical restraint. Review of personnel files for Staff D and other agency staff showed that restraint and abuse prevention training had not been completed by the facility prior to them providing resident care and prior to the incident. This lack of required training and the subsequent use of an improvised hand restraint on the resident led to the identified deficiency related to improper use of physical restraints.
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