F0600

J

Resident Unlawfully Restrained to Bed With Zip Ties by LPN

Watertown, New York Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from abuse and neglect when an LPN used zip ties to restrain the resident to their bed for approximately 45 minutes to one hour during an overnight shift. Facility policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff education on appropriate interventions for aggressive behaviors and on reporting abuse and neglect. Despite this policy, the resident, who had Alzheimer’s dementia, Parkinson’s disease, moderately impaired cognition, and was care planned as an elopement/wandering risk, was subjected to an unlawful restraint using zip ties attached to the bed’s able riser/side rail.

Resident #3’s care plan identified them as disoriented to place, with impaired safety awareness and wandering behavior, and interventions included distraction with activities, food, conversation, and allowing time to verbalize feelings and fears. On the night of the incident, the resident was reportedly up frequently, leaving their room, moving around the unit, and had a history of frequent falls from bed with pressure mats in place to alert staff. According to interviews, the LPN became increasingly upset and “tired” of responding to the resident’s bed alarms and movements, and stated an intention to give the resident “personal protective bracelets,” despite being told by a CNA that restraining residents was illegal. Subsequently, the LPN and a CNA took the resident back to bed, and later the resident was found with a sock over the hand and zip ties securing the wrist to the bed rail/able riser.

Multiple staff statements described witnessing or discovering the restraint and related events. One CNA reported seeing the LPN place a white zip tie around the resident’s wrist and connect it to the bed rail in the down position, with a black zip tie intertwined around the rail, and hearing commotion near the resident’s room. Another CNA later observed the resident sleeping with a sock and zip tie on the wrist and cut the zip tie off, placing it at the nurse’s station. Staff also reported the LPN holding the resident’s door shut while the resident attempted to open it, telling the resident through the door to go back to bed. When the oncoming LPN was informed of the incident, they assessed the resident, found no physical injuries, and discovered used zip ties under the bed and in the trash. The facility president confirmed that zip ties had previously been used only to secure old bed rails and that those beds had been removed, indicating there was no legitimate need for zip ties on the unit at the time of the incident. The police report documented that plastic zip ties had been used to restrain the resident’s hand to the bed, and the facility’s investigation concluded that the LPN had zip tied the resident’s wrist to the bed rail, constituting abuse and resulting in Immediate Jeopardy Past Non-Compliance.

Removal Plan

• Resident #3 was immediately assessed by a registered nurse for physical and psychological harm; the physician and family were notified, and the resident's care plan was revised to include potential for abuse.
• Licensed Practical Nurse #7 and Certified Nurse Aides #4 and #6 were placed on administrative leave pending investigation.
• Certified Nurse Aide #4 received discipline for timely reporting and received additional education.
• Licensed Practical Nurse #7 and Certified Nurse Aide #6 were terminated.
• The accused Licensed Practical Nurse's actions were reported to the Office of Professions.
• The facility initiated training regarding restraints, dementia care, abuse prevention, identification, and reporting.
• All staff were educated.
• A full house abuse assessment was conducted on each resident.
• The facility initiated restraint audits for all residents, and findings were reported to the Quality Assurance Team.