F0604

G

Resident Restrained to Bed With Sheet Resulting in Abdominal Bruising

Waynesburg, Pennsylvania Survey Completed on 02-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from physical restraints, as required by facility policy and regulatory standards. Facility policies defined a physical restraint as any manual method or material attached or adjacent to the resident’s body that the resident cannot easily remove and that restricts freedom of movement, including tightly tucked sheets that prevent a resident from getting out of bed. The facility’s abuse and restraint policies also stated that even unintentional use of restraints must be recognized and reported by staff.

The resident involved, identified as R1, had diagnoses including heart failure, anxiety, depression, and dementia, with a BIMS score of 9 indicating moderate cognitive impairment. R1 had a care plan for fall risk related to gait and balance problems, with staff directed to follow the facility’s fall protocol. A weekly skin evaluation completed prior to the incident did not show new skin issues, and nurse aide skin observations from the beginning of the month through the date of discovery consistently documented no discoloration or other skin concerns.

On the morning of the incident, a head-to-toe assessment documented scattered fading discolorations on the resident’s extremities and a 0.5 x 4 cm linear purple discoloration on the left lower abdomen/pelvis. That same day, the DON documented that it had been reported that R1 was found in bed with a sheet over her, tied to the bed to hold her down at the beginning of the 6 a.m.–2 p.m. shift. Multiple staff statements described the sheet as rolled or placed across the resident’s abdomen/hips, with the ends looped or tied to the bedframe from one side of the bed to the other, and the resident’s hands underneath the sheet so she could not move them. Staff reported difficulty in untying the knot and indicated that the configuration of the sheet restricted the resident’s movement.

Several nurse aides provided statements acknowledging their involvement or knowledge of the sheet being used in this manner. One nurse aide stated that after the resident reportedly fell twice onto a fall mat during the night, she and another aide placed a bed sheet across the resident’s hips and “lightly looped” it through the bed so the resident could not fall, and that they did not realize this could be considered a restraint. Another aide confirmed helping to get the resident off the floor and then looping a sheet around the bed to keep the resident safe, also stating she did not realize this was a restraint. A different aide reported discovering the sheet tied to the bedframe at two points and showing it to the oncoming day-shift aide, who told her to leave it in place. Other staff, including an RN and LPN on duty, stated they were unaware of any fall or did not observe the sheet in place when they were in the room. During a later interview, the Nursing Home Administrator and DON confirmed that the facility failed to ensure residents were free from physical restraints, and that staff had restrained the resident to the bed with a bed sheet, which caused abdominal bruising.