Failure to Protect Resident From Unauthorized Physical Restraint and Abuse
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Assess Bolsters as Possible Restraints: The facility failed to identify a bolster as a possible physical restraint and did not assess whether bolster use was a restraint for two residents. One resident had Parkinson’s disease, anxiety, and limited transfer ability, and the other had hemiplegia, anxiety, depression, and a history of falls related to decreased safety awareness, altered cognition, and impulsivity. Both residents were observed in bed with mattresses that had bilateral raised edges, and their records did not show assessments or ongoing evaluations for bolster use.
Beds were positioned against the wall for three residents, restricting movement and being treated as a restraint without physician orders, informed consent, assessments, or care plans. The residents had dementia and limited mobility, and staff stated the bed placement prevented them from getting out on one side and could be considered a restraint. The DON and DSD both stated that beds against walls can be a restraint and require orders, consent, assessment, and care planning.
A DON used his/her body to restrain a resident by straddling and bracing the resident’s leg while attempting to administer a court-ordered Haldol injection after the resident refused and became combative. The resident had a history of refusing psychotropic medication, and the record showed the injection was not documented as given. Interviews with the NP and LPN indicated the DON’s actions would be considered a restraint and not appropriate.
Improper Use of Geri-Chair as a Physical Restraint: A resident with dementia and confusion was placed in a Geri-chair in a Trendelenburg-like position without documentation of a restraint need, a physician order, or tried alternatives. While being pushed outside by the AD, the resident appeared upset, said he did not want to go outside, and stated he wanted to get out of the chair; the DOR said he could sit well in a regular wheelchair, while a CNA said the chair position was used so he would not try to get up and fall.
A resident with dementia and severe cognitive impairment was found in bed with a flat sheet tied across her torso from side rail to side rail, restricting movement without a physician order. An RN removed the sheet and found no injury or distress. The CNA later stated she used the sheet to keep the resident from getting out of bed while staff were rounding, and the DON confirmed the resident’s care plan addressed supervision and fall prevention without restraints.
Use of Handcuffs as a Physical Restraint Without a Medical Symptom: A resident with diagnoses including AAA without rupture and DM was placed on a care plan that incorporated law enforcement handcuffs because of criminal history and jail-related supervision needs. The order allowed handcuffs as needed for safety, but it did not identify a medical symptom for restraint use. Staff interviews showed conflicting directions about when handcuffs were required, who could apply or remove them, and whether the resident was to be handcuffed when the guard briefly left the room.
Failure to Assess Bolsters as Possible Restraints
Penalty
Summary
The facility failed to identify a bolster as a possible physical restraint and failed to assess the functional status of two residents to determine whether the use of a bolster was a restraint. The facility’s restraint policy stated that a physical restraint is any manual method or physical or mechanical device, material, or equipment 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. Resident R2 had diagnoses including high blood pressure, Parkinson’s disease, and anxiety. The clinical record showed a physician order for a bariatric bed with bariatric mattress and bolster overlay, along with bilateral assistive handrails to aid positioning, and the care plan included the same interventions. During observation, R2 was lying in bed with a mattress that had bilateral raised edges on the top and bottom portions. Resident R87 had diagnoses including hemiplegia, anxiety, and depression. The record showed an order for bilateral bed rail bolsters while in bed as tolerated, and the care plan included a contour mattress with bolster overlay and bilateral foam wedges for positioning. During observation, R87 was also lying in bed with a mattress that had bilateral raised edges on the top and bottom portions. For both residents, the clinical record did not identify assessments or ongoing evaluations for the use of bolsters, and the Regional Director of Clinical Services confirmed the facility failed to assess whether the bolster was a restraint.
Beds Positioned Against Walls Used as Restraints Without Required Orders
Penalty
Summary
The facility failed to ensure that three sampled residents were free from physical restraints when staff positioned their beds against the walls of their rooms without physician orders, informed consent, assessments, or care plans. The report identified Residents 106, 117, and 129 as having beds placed with the left side against a wall, which restricted their ability to get out of bed on that side. The facility’s restraint policy, last revised 5/1/2026, defined restraints to include beds against walls and required an RN assessment, physician’s order, informed consent, and care plan before use. Resident 106 had diagnoses including dementia, toxic encephalopathy, and COPD, and the H&P stated the resident did not have capacity to understand and make decisions. The MDS indicated difficulty with cognitive skills in new situations and maximal assistance needed for rolling left and right in bed. During observation, the resident was lying in bed with the left side against the wall. CNA 1 stated the bed was too close to the wall and could be considered a restraint because the resident would not be able to get out on the left side. LVN 6 also stated the bed positioning could restrict movement and was being used to prevent the resident from falling off the left side. Resident 117 had diagnoses including dementia, reduced mobility, and hypertension, and the H&P stated the resident did not have capacity to understand and make decisions. The MDS indicated severe cognitive impairment and maximal assistance needed for rolling in bed. The resident was observed with the left side of the bed against the wall. CNA 2 stated the bed should be moved away from the wall because it restricted the resident from getting out on the left side, and LVN 7 stated the positioning could be considered a restraint. Resident 129 had diagnoses including dementia, hypertension, and dorsalgia, and the H&P stated the resident had fluctuating capacity to understand and make decisions. The MDS indicated the resident was rarely/never understood and required moderate assistance to roll in bed. The resident was also observed with the left side of the bed against the wall. CNA 3 stated the bed was always positioned against the wall, and LVN 6 stated it was positioned there because the resident was at risk for falls and would not be able to get out on the left side.
Improper Use of Physical Restraint During Medication Administration
Penalty
Summary
The facility failed to ensure a resident remained free from physical restraint when the DON used his/her body to hold and stabilize the resident’s leg while attempting to administer a Haldol Decanoate injection. The facility’s restraint policy stated restraints may only be used for the resident’s safety and well-being after other alternatives have been tried unsuccessfully, and defined a physical restraint as any manual method or device that restricts freedom of movement. During the incident, the DON documented that the resident became combative and aggressive, and that he/she positioned himself/herself with his/her back toward the resident and braced his/her legs against the resident’s leg to prevent movement while attempting the injection. Resident #1’s record showed a quarterly MDS indicating the resident was cognitively intact and received an antipsychotic medication. The care plan noted the resident had a court order to receive psychotropic medication monthly by the least restrictive means necessary and that the resident was at risk for adverse reactions related to psychotropic medications used for behavior management, hallucinations, and paranoid schizophrenia. The physician order summary included an order for Haloperidol Decanoate intramuscularly every 28 days, and the July 2026 MAR did not document that the injection was administered, with staff noting the resident often refused medication. The resident’s progress note documented that the DON, a CNA, and a nurse went to the resident’s room to administer the injection, that the resident refused, and that staff explained the court order. Staff documented that the DON attempted to give the medication, the resident hit the DON and knocked the needle out of the DON’s hand, and the resident continued to curse and yell. During interviews, the DON said he/she straddled the resident’s leg and braced against it to prevent movement, and said he/she did not contact the physician because he/she believed the court order required administration. The NP and LPN stated that straddling and bracing the resident’s leg to give a shot would be considered a restraint and was not appropriate, while the administrator described the situation as a gray area because of the court order.
Improper Use of Geri-Chair as a Physical Restraint
Penalty
Summary
The facility failed to ensure that one sampled resident with a history of encephalopathy, dementia, and depression was free from the use of a physical restraint unless needed for medical treatment. Resident 6 was assessed as forgetful and unable to make decisions, required one-person assistance with activities of daily living, and had no written documentation in the medical record showing a need or evaluation for restraint, no physician order for a restraint, and no alternative measures used before the resident was placed in a Geri-chair. During observation, Resident 6 was seated in a Geri-chair in a Trendelenburg-like position while being pushed by the Activity Director to the patio. The resident was observed with a tightened jaw, frowning, attempting to turn from side to side, and verbally stating that he did not want to go outside and wanted to get out of the Geri-chair. The Social Services Director stated the resident was confused and could not get up on his own while in the chair, and the Director of Rehabilitation Services stated the resident had good trunk control in a wheelchair and did not need a Geri-chair because he could sit well in a regular wheelchair. A CNA stated she positioned the resident with his head lower than his legs in the Geri-chair so he would not try to get up and fall.
Unauthorized Sheet Used as a Physical Restraint
Penalty
Summary
The facility failed to ensure a resident was free from the use of a physical restraint when a flat sheet was tied from one side rail to the other across the resident’s torso while she was in bed. The resident had diagnoses of dementia, hypertension, and anxiety, and the most recent MDS indicated no BIMS score, severely impaired cognitive skills for daily decision making, and dependence for bed mobility, surface-to-surface transfers, and all activities of daily living. According to the incident and investigation records, an RN observed the resident restrained in bed with the sheet secured across her body. The sheet was removed immediately, and the resident was assessed with no injury or distress. The facility’s investigation identified that the restraint had been applied by a CNA during the night shift after the resident was transferred from a geri recliner to bed. The CNA stated she folded a flat sheet and tied it to the quarter side rails across the resident’s torso to keep her from getting out of bed while staff were rounding on other residents, and she acknowledged that it was a restraint. The resident did not have a physician’s order for any restraint, and the DON confirmed that the resident’s care plan addressed supervision and assistance for safety and fall prevention without the use of restraints. The facility records also show that the CNA was terminated for the unauthorized use of a physical restraint and violation of resident rights, and the Administrator and DON stated that the action violated facility policy and resident rights.
Use of Handcuffs as a Physical Restraint Without a Medical Symptom
Penalty
Summary
The facility failed to ensure a resident remained free from physical restraints that were not required to treat a medical symptom when it incorporated the use of law enforcement handcuffs into the resident’s care plan. The resident was admitted with diagnoses including abdominal aortic aneurysm without rupture and diabetes. The care plan, initiated after admission, stated that a physical restraint was deemed necessary by county policy because of the resident’s criminal history, that corrections staff would remain in the room or observe the resident at all times, and that the resident would be handcuffed if security left the room. The care plan also stated staff would place and remove handcuffs as needed. The informed consent identified handcuffs as the restraint when the resident was not in view of the security guard due to the need for 24-hour supervision related to admission to the hospital and SNF from jail. The order summary report included an order allowing handcuffs to be applied as needed for safety every shift, but it did not identify a medical symptom that warranted restraint use. During interviews, staff described that the resident was to be handcuffed to a shower chair or bed when the guard left the room, while the correctional officer stated he had been told handcuffing was not necessary if he briefly stepped away. The DON stated the resident was to be handcuffed to the bed whenever the guard left the room, that skin assessments related to the handcuffs were to be completed, and that only guards were to apply or remove the handcuffs. The administrator stated the resident was handcuffed whenever the guard stepped away and that facility staff could remove the handcuffs in an emergency. Facility policy regarding physical restraints was requested but not provided.
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