F0604

J

Failure to Protect Resident From Unauthorized Physical Restraint and Abuse

Mission Hills, California Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident’s right to be free from physical restraints and abuse. A resident with dementia, Alzheimer’s disease, muscle weakness, gait and mobility abnormalities, and no capacity to make decisions was admitted in August 2025. The resident’s MDS dated 12/8/2025 showed severe cognitive impairment, with the resident rarely understanding and rarely being understood, and being dependent or requiring assistance for most ADLs. A fall risk assessment on the same date identified the resident as high risk for falls with a score of 21. These records established that the resident was cognitively impaired, physically vulnerable, and dependent on staff for care and safety.

On the night in question, CNA 1 was assigned to the resident during the 11 p.m. to 7 a.m. shift and remained on duty until after 7 a.m. LVN 1 reported that around 2 a.m. the resident began chanting, which became louder and more frequent. LVN 1 asked CNA 1 to check on the resident; CNA 1 returned and stated the resident was okay and always behaved that way. Approximately 10 minutes later, the resident again began yelling in her own language. At around 2:50 a.m., LVN 1 entered the resident’s room, found the blanket on the floor, and observed the resident lying in bed making wiggly body movements. LVN 1 then saw that the resident’s wrists were firmly tied together in front of her with a long scarf, with no wiggle room and no ability for the resident to move or release her hands. LVN 1 untied the scarf and assessed the resident, noting no visible injury.

The facility’s own policies required that any physical restraint be preceded by a licensed nurse’s assessment, IDT involvement, determination of need, identification of the least restrictive device, and appropriate documentation and consent. The restraint policy also stated that residents are to be provided a restraint-free environment and that restraints are not to be used for discipline or staff convenience. The abuse prevention policy stated that each resident has the right to be free from abuse, neglect, and mistreatment, that the facility has zero tolerance for abuse, and that staff accused of abuse, neglect, or mistreatment are to be suspended until the investigation is complete. The DON and Administrator both stated that tying the resident’s hands with a scarf constituted a physical restraint and physical abuse, and the Administrator indicated he believed CNA 1 tied the resident’s hands for the CNA’s convenience because the resident was restless. Despite this, CNA 1, who was suspected of tying the resident’s hands and was found sleeping during that time, was not immediately removed from duty and continued to provide care to the resident until the end of the shift, contrary to the facility’s abuse prevention policy.

Removal Plan

• LVN 1 reported the alleged abuse incident to Human Resources and the Director of Nursing, stating Resident 1 was found with hands bound by a scarf; LVN 1 removed the scarf and notified the Ombudsman.
• The facility suspended CNA 1 pending Human Resources investigation.
• LVN 1 received a written warning for failing to report the incident to the RN Supervisor on duty.
• The facility terminated CNA 1.
• The Director of Staff Development reported CNA 1 to the CNA Licensing Board.
• RN Supervisors conducted rounds on all units to visually observe all residents for any signs of physical restraints, inappropriate devices functioning as restraints, or signs of abuse/neglect; no other residents were identified.
• RN Supervisors conducted another facility-wide sweep of all residents to screen for restraints; no other residents were identified.
• Human Resources and the Administrator suspended LVN 1 for failure to follow facility policy.
• The Assistant Director of Staff Development initiated in-service training for facility staff regarding restraints, with the Assistant DSD and DSD continuing in-services until completion.
• During orientation, the facility will in-service newly hired staff on abuse and physical restraints, including review of the Abuse Prevention and Prohibition Program policy, resident rights, immediate reporting requirements, zero-tolerance policy and requirement to report suspected abuse immediately, and documentation requirements.
• The Director of Nursing created a root cause analysis.
• The Administrator and Director of Nursing instructed staff that there will be immediate removal of staff from duty when abuse/neglect is suspected.
• Shift-to-shift report will include reporting of any suspected abuse and immediate suspension of staff involved.
• Department Managers, Managers of the Day, and the RN Supervisor on duty will conduct daily rounds on every shift (including weekends and holidays) to validate no restraints observed weekly for four weeks, then monthly for two months, to ensure residents feel safe and are free from restraints.