Failure to Timely Report Suspected Restraint Use as Possible Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of possible abuse involving the use of restraints on a resident to the State Survey Agency, as required by facility policy and regulation. The resident involved had multiple diagnoses, including Down syndrome, cerebral palsy, type 2 diabetes mellitus, congestive heart failure, chronic atrial fibrillation, epilepsy, chronic kidney disease stage 3, anxiety, restlessness and agitation, lumbar compression fractures, abdominal distension, obstructive uropathy, and urogenital implants. The resident’s MDS showed severely impaired memory and decision-making but no impairment in upper or lower extremity function, and indicated that no restraints or chairs that prevent rising were in use. The care plan documented limited mobility, use of a wheelchair, and need for staff supervision for short ambulation. On the early morning in question, two dietary staff members arriving for day shift observed the resident seated or reclined in a Broda (medical) chair near the nurses’ station. One dietary staff member reported that the resident asked for tea and appeared to have immobile arms, and believed the resident’s wrists were secured with Velcro, though she was uncertain due to dim lighting. She also observed the resident in disposable underwear with a sheet over his waist. The other dietary staff member observed the resident reclined, covered with a white blanket, appearing unable to move his arms or legs, with only his head moving forward, and heard the resident say, “I am done, I am done.” This staff member stated she reported her observations to nursing staff, who told her the resident had been awake all night and would remain in the chair for a while. Neither dietary staff member reported their observations to administration at that time. Later that morning, an Infection Control LPN observed the resident reclined in a Broda chair with feet elevated and recognized that the reclined Broda chair could be considered a restraint, instructing another LPN to transfer the resident to his regular wheelchair. She stated she did not see restraints or distress. The two dietary staff did not bring their concerns to their supervisor until two days later during a morning meeting, at which time they were asked for written statements and the concern was then reported to administration. The Administrator was not notified until that point, and the Facility-Reported Incident was submitted to the State Agency only after this delayed internal reporting. Facility policies required all allegations of abuse, neglect, or exploitation, including potential restraint use, to be reported immediately to the Administrator and appropriate agencies, and staff interviews confirmed that all staff, including non-nursing staff, were expected to immediately report suspected abuse or restraint use, even if uncertain. The delay from the initial observations to notification of administration and reporting to the State Agency constituted the failure to timely report the suspected abuse.
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