F0604

J

Improper Use of Sheet as Physical Restraint During Mealtime

Cranbury, New Jersey Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the use of a physical restraint on a resident with severely impaired cognition, behaviors, and an underlying C-diff infection, in a manner that was for staff convenience and not required to treat a medical symptom. The facility’s own restraint policy stated that restraints were to be used only for the safety and well-being of residents, only after other alternatives had been tried unsuccessfully, and never for discipline, staff convenience, or fall prevention. Physical restraints were defined in the policy as any manual method or device attached or adjacent to the resident’s body that the individual cannot remove easily and that restricts freedom of movement or normal access to one’s body.

The resident had dementia, dysphagia, anxiety disorders, and osteoporosis, and an MDS assessment showed a BIMS score of 0/15, indicating severely impaired cognition. The care plan documented impaired cognitive function related to dementia and behavior issues including grabbing, pushing, putting small objects in the mouth, removing briefs and leaving them anywhere, and removing an ace bandage from the left lower extremity. The resident was also on antibiotics and had C-diff, with care plan interventions including contact isolation, use of gowns and masks when changing contaminated linens, disinfection of equipment, and education of resident, family, and staff regarding infection prevention. Additional care plan entries indicated the resident required contact precautions related to C-diff, including disposal of soiled products per policy, placement in a private room, assistance with position changes, and appropriate handwashing.

On the evening of the incident, a CNA reported having been told that the resident was on isolation precautions for C-diff and had behaviors of taking off clothes and briefs. Around dinner time, the CNA served the resident’s meal and placed a sheet on the resident’s lap to prevent the resident from tampering with their brief or removing their pants during mealtime. The CNA stated that the sheet repeatedly fell to the floor and, due to concern that the resident, who ambulated impulsively, could trip or fall on the sheet, the CNA loosely tied the sheet around the resident’s waist and behind the wheelchair. Later that evening, the resident’s family member entered the room, found the resident alone in a wheelchair with the dinner tray in front, and discovered a white bed sheet wrapped around the resident’s waist and tied behind the wheelchair. When notified, the nursing supervisor observed the resident sitting upright in the wheelchair with the sheet over the lap and loosely secured behind the back, with no staff present in the room, and then removed the sheet. This use of a tied sheet around the resident’s waist and wheelchair constituted a physical restraint imposed for care convenience and not required to treat the resident’s medical symptoms, leading to an Immediate Jeopardy determination beginning at the time the sheet was applied during dinner.

Removal Plan

• Certified Nursing Assistant (CNA) #1 was immediately removed from resident care and suspended pending investigation.
• Nursing staff conducted an immediate comprehensive head-to-toe physical, skin, and neurological assessment, with no injuries identified.
• The resident's primary medical provider was notified.
• Responsible parties present in facility were notified.
• The NJDOH and Office of the Ombudsman were notified.
• Ongoing monitoring orders were initiated for three (3) consecutive days.
• All residents with a Brief Interview for Mental Status (BIMS) score of 11 or less received precautionary skin checks.
• All residents with BIMS score of 12 or higher were interviewed and denied witnessing or experiencing any abuse or concerning behavior related to CNA #1's assignment.
• Written statements were obtained from all staff involved.
• A full-house in-service training was initiated for all staff with emphasis on CMS F604 (Freedom from Abuse, Neglect, and Exploitation).
• Education reinforced that no improvised devices, linens, or methods may be used in any manner that could be perceived as restrictive, regardless of intent.
• Staff were re-educated on the requirement that only approved, care planned, and policy compliant interventions may be utilized at all times.