Unnecessary Wanderguard Use and Movement Restrictions on Cognitively Intact Resident
Summary
The deficiency involves the use of a Wanderguard (elopement-prevention device) on a cognitively intact resident without adequate assessment, documentation, or evidence of unsafe wandering or elopement behaviors. Facility policies on elopement and wandering management state that elopement applies to residents with impaired cognition and/or poor safety awareness, and that residents will be assessed for elopement risk upon admission and at set intervals. The Wanderguard policy specifies that restraining an ambulatory resident simply to prevent wandering is unacceptable and that residents should feel allowed their freedom while under close observation. Despite these policies, the resident was placed on a Wanderguard, and the Medical Safety Device Assessment used for Wanderguard placement was documented as incomplete. The resident’s records showed an admission date with diagnoses including Type 1 diabetes mellitus, anxiety disorder, major depressive disorder, and an initial diagnosis of dementia that was later questioned. A speech therapy discharge summary documented a MOCA score of 28/30, indicating no severe cognitive impairment, and prior cognitive functioning without need for supervision. A neuropsychological evaluation reported that dementia screening was negative, and the facility’s medical director agreed with a diagnosis of neurocognitive disorder but disagreed with the dementia diagnosis. The admission MDS documented a BIMS score of 15, indicating intact cognition, and no wandering behaviors exhibited. The resident’s care plan, however, labeled the resident as an elopement risk/wanderer related to a history of attempts to leave the facility unattended, called for monitoring location every 15 minutes, and documented use of a security bracelet related to poor safety awareness and forgetfulness associated with Type 1 diabetes, but did not include documented evidence of unsafe wandering or elopement attempts. The resident repeatedly reported psychosocial distress related to the Wanderguard and movement restrictions. In complaint intake forms, the resident stated that the Wanderguard prevented leaving the unit to attend activities elsewhere on campus, caused feelings of isolation among residents with cognitive deficits, and contributed to depression and negative effects on mental health. The resident reported feeling like a “chained elephant in a cage” and expressed a desire for more rights and the ability to do enjoyable activities, including worship and socializing in the independent living area where the resident had previously lived. Staff interviews confirmed the resident’s emotional distress: the SSD and NP reported the resident cried, shook, and became upset about loss of independence and Wanderguard use, and an LPN stated the resident felt she was losing independence due to the device. Facility staff provided varying accounts regarding the rationale for the Wanderguard. The DON stated the resident was assessed as a moderate elopement risk and that the Wanderguard was placed after this assessment, citing concerns about diabetic management, missed insulin doses, and inconsistent blood sugar monitoring, including an episode of blood sugar at 400 when the resident left without appropriate checks. The MD stated the Wanderguard was applied after two less restrictive safety measures failed, describing periods of clarity followed by behavioral escalation, removal of the device, attempts to leave to see the resident’s husband and dog, and aggressive behaviors, and characterized some unsupervised departures as elopement. However, the SSD stated she was unaware of any elopement attempts and confirmed the resident’s BIMS score of 15 with no cognitive concerns. The spouse reported that the resident was capable of independent activities in the area, believed the resident could leave the main building if staff were informed, and stated that after the resident left to attend to her dog and returned, the Wanderguard was placed. Despite the resident’s intact cognition and incomplete documentation of elopement risk and less restrictive interventions, the Wanderguard and associated movement restrictions remained in place, limiting the resident’s freedom of movement and contributing to psychosocial distress.
Penalty
Resources
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A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
A resident with severe cognitive impairment, dementia, and behavioral symptoms including wandering was observed seated in a wheelchair at the dining table on multiple occasions with the wheelchair locked on one side. A CNA reported that the resident could not operate the wheelchair locks and that staff locked the wheelchair to keep the resident at the table and prevent wandering during meals, despite acknowledging staff were not supposed to lock it. Facility policy states residents must be free from physical restraints not required to treat a medical symptom, making this use of the wheelchair lock a noncompliant restraint.
A resident with multiple chronic conditions and intact cognition, care planned for fall risk and restful sleep, became agitated and combative during a night shift. After medication was given and the resident later transferred to bed, a CNA placed a mattress upright against one side of the bed and secured it with a locked chair, while the other side of the bed was against the wall, effectively preventing the resident from exiting the bed. Incoming CNAs observed the resident asleep with bedding and pillows arranged in a way that further restricted movement, and the DON confirmed the resident had been restrained in violation of the facility’s restraint policy.
A resident with a history of aggressive behavior was physically restrained in a wheelchair using a bath sheet held by an LPN to prevent harm to staff and others. The restraint was not documented in the medical record, and there was no physician order for its use. This action was confirmed through staff interviews and met the facility's definition of a restraint.
A resident with severe cognitive impairment and a history of falls was placed in a new wheelchair with a harness and seatbelt, but staff used these devices without proper assessment, physician orders, or adequate training. There was confusion among staff and family about when the harness should be used, and inconsistent application led to a red mark on the resident's neck. The facility did not follow its policy requiring interdisciplinary assessment before using restraints.
A resident with severe cognitive impairment and ventilator dependence was placed in mitt restraints due to repeated attempts to remove medical equipment. The facility did not consistently document the ongoing need, usage, or evaluation of the restraints, nor did the care plan include specific interventions or monitoring related to restraint use. Staff interviews confirmed a lack of structured documentation and re-evaluation, despite facility policy requiring these actions.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
Improper Use of Wheelchair Lock as Physical Restraint During Meals
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from physical restraints not required to treat a medical symptom. The resident was admitted on 10/06/23 with diagnoses including unspecified dementia, hyperlipidemia, recurrent major depressive disorder, anxiety disorder, and cognitive communication deficit. A Minimum Data Set (MDS) assessment dated 02/02/26 documented that the resident was severely cognitively impaired, required set-up/clean-up assistance with eating, and was dependent for toileting, showering, and personal hygiene. The resident also exhibited occasional behaviors of physical aggression, verbal aggression, other behaviors, rejection of care, and wandering. On 03/11/26 at 10:34 A.M., the resident was observed alert, seated in a wheelchair at the dining room table, with the wheelchair locked on the left side. A subsequent observation at 11:49 A.M. the same day showed the resident still at the dining room table eating lunch in the same location, with the wheelchair again noted to be locked on the left side. During an interview at 2:22 P.M., a CNA stated that the resident was not able to lock or unlock the wheelchair and explained that staff locked the wheelchair to ensure the resident remained at the table and did not wander during meals. The CNA also verified that staff were not supposed to lock the wheelchair. The facility’s abuse and neglect policy states residents must be free from any physical restraint not required to treat a medical symptom, indicating that the practice of locking the wheelchair for behavior control was inconsistent with facility policy.
Plan Of Correction
F604 Right to be free of physical restraints The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident # 30 is free of restraint. Resident #30 was assessed by the DON for any negative effects from being placed at the table with the WC locked on one side on 3-17-26, with no negative outcomes. On 3-17-26, going forward, the residents' chair is not locked when sitting at the table. How will you identify other residents having the potential to be affected by the same deficient practice, and what corrective action will be taken? Reviews of residents who resided on the same unit with a dementia diagnosis have the potential for the same practice. An audit of these residents done by the MDS nurse or DON began on 3-24-2026 and resulted in no evidence of restraint use. On-going, there will be a random sample of 5 residents five days a week for four weeks. The audits began 3/24/26, and if any concerns are noted, they will be immediately corrected and staff re-inserviced. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. On or by 4-9-2026 DON/designee educated nursing staff in "The right to be free of any physical restraints". Reminder notice for nursing staff placed at the nurses' station by the DON on 4-8-26 that no residents shall have their wheelchairs locked while sitting at the dining tables. How the corrective action will be monitored to ensure the deficient practice will not recur. An audit is in place to review residents on Florence for their wheelchairs that they are not being locked when the residents are seated independently The auditor is the RN MDS nurse, The DON ensures the audits are being completed. The audits began 3/24/26, and if any concerns are noted, they will be immediately corrected and staff re-inserviced. A random sampling of 5 residents, 5 days a week X4 weeks, with results submitted weekly to QAPI meeting for the QAPI team to evaluate the success of if any further guidance is needed.
Resident Restrained in Bed Using Mattress and Chair Without Proper Authorization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from unnecessary physical restraints. The resident had diagnoses including cirrhosis with ascites, diabetes mellitus, COPD, and depression, with an MDS showing intact cognition, partial assistance with ADLs, supervision with transfers, and independence with bed mobility. The resident’s care plan addressed a need for restful sleep and identified fall risk, with interventions such as keeping the room quiet, dimming lights, offering a back rub or snack, and using a fall mattress on the floor next to the bed or a perimeter-defining mattress. On the night in question, nursing documentation indicated the resident became agitated, restless, combative, attempted to toss herself to the floor, and was yelling for her son. A hospice nurse assessed the resident and obtained an order for Ativan every four hours, after which the resident became calm. Later during the night shift, a CNA reported that the resident was restless, grabbing at the air, not responding to direction, and attempting to throw herself out of a chair. At approximately 5:45 a.m., this CNA transferred the resident to bed, covered her with a bedsheet, and placed a mattress upright against the open side of the bed, secured in place with the resident’s locked chair, while the other side of the bed was against the wall. Day-shift CNAs arriving later that morning observed the resident asleep in bed with a mattress pressed against one side of the bed, held in place by a locked chair, and the opposite side of the bed against the wall. One CNA reported that a sheet and blanket were tucked under the mattress over the resident, along with pillows positioned in a way that prevented the resident from exiting the bed, making it impossible for her to get out. Another CNA confirmed seeing the mattress and locked positioning chair against the bed. The DON confirmed that the facility verified the CNA had restrained the resident in bed by placing the mattress against the bed in this manner, resulting in the resident being unable to exit the bed, contrary to the facility’s policy that residents have the right to be free from physical restraints and that any ordered restraint must be the least restrictive and used for the least amount of time with ongoing reevaluation.
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.
Failure to Ensure Proper Assessment and Training Before Use of Wheelchair Restraint
Penalty
Summary
The facility failed to ensure that a resident was not restrained in a wheelchair without adequate training, assessments, and physician orders. The resident, who had diagnoses including dementia, Down syndrome, severe cognitive impairment, and a history of falls, was provided with a new custom-fitted wheelchair equipped with a seatbelt and harness. The harness and seatbelt were intended to aid in positioning and prevent falls, but their use was not properly assessed or ordered prior to implementation. Staff began using the harness and seatbelt immediately after the wheelchair's arrival, despite not having received comprehensive training or clear guidance from therapy or the interdisciplinary team. There was confusion among staff regarding when and how the harness should be used, with some staff applying it routinely and others only in specific situations such as during meals or when the resident was leaning significantly. The resident's family expressed conflicting wishes about the use of the harness, at times requesting its use and at other times objecting to it, particularly after observing a red mark on the resident's neck. Documentation and interviews revealed that staff were not uniformly educated on the proper application of the harness, and therapy staff were not present for the initial fitting or evaluation of the wheelchair. Orders and assessments for the use of the harness and seatbelt were completed only after their use had already begun. The lack of a coordinated assessment and training process led to inconsistent and potentially unsafe application of the harness, resulting in physical signs of harm such as a red mark on the resident's neck. Staff statements indicated uncertainty about whether the harness constituted a restraint and how it should be used, and there was no clear documentation or communication regarding the intended protocol. The facility's own policy required an interdisciplinary assessment and consideration of less restrictive alternatives before implementing restraints, which was not followed in this case.
Failure to Document and Re-Evaluate Ongoing Use of Physical Restraints
Penalty
Summary
The facility failed to ensure proper documentation and ongoing evaluation for the use of physical restraints on a resident with multiple complex medical conditions, including acute respiratory failure, COPD, encephalopathy, ventilator dependence, and significant cognitive impairment. The resident was admitted with a history of attempting to remove life-sustaining medical equipment, leading to the use of mitt restraints as ordered by the provider. However, the provider order lacked essential details such as the specific diagnosis justifying the restraint, instructions for breaks in restraint usage, and requirements for monitoring the effectiveness of less restrictive interventions. Nursing progress notes indicated that mitt restraints were applied and skin assessments were performed on select dates, but there was no consistent documentation of the ongoing need, usage, or evaluation of the continued use of restraints as required by facility policy. The care plan did not include specific goals or interventions related to the mitt restraints, nor did it address ongoing monitoring or plans for removal. The Medication Administration Record showed that mitt restraints were signed off for each shift, but this did not substitute for the required comprehensive documentation and evaluation. Interviews with facility staff, including the DON, respiratory therapist, nurse practitioner, and LPN, revealed a lack of clarity and consistency in the documentation and management of restraints. Staff acknowledged the need for restraints due to the resident's behaviors but confirmed that there was no daily checklist or structured process for documenting alternatives attempted, ongoing re-evaluation, or effectiveness of the restraint. The facility's own policy required documentation of medical symptoms warranting restraint use, less restrictive alternatives, and ongoing re-evaluation, none of which were adequately present in the resident's record.
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