Failure to Timely Report and Protect Resident After Discovery of Bound Wrists
Penalty
Summary
The facility failed to implement its Abuse Prevention and Prohibition Program by not reporting an allegation of abuse to the State Survey Agency, local law enforcement, adult protective services, and the Ombudsman within two hours as required by policy. During the night shift, an LVN discovered a resident with dementia and Alzheimer's disease lying in bed with her wrists firmly bound together in front of her with a long scarf tied in a figure-eight pattern multiple times, which the LVN described as having no wiggle room and no way for the resident to get out. The LVN took a photograph of the resident’s bound wrists, untied the scarf at approximately 3:00 a.m., and later notified the DON and Resident Care Manager (RMN) around 7:15–7:20 a.m., resulting in a delay of about three hours in reporting the suspected abuse to the Administrator and triggering external reporting. The resident involved had been admitted with diagnoses including dementia, Alzheimer's disease, muscle weakness, and gait and mobility abnormalities. A prior H&P documented that the resident did not have capacity to understand and make decisions. The MDS indicated the resident rarely understood and was rarely understood, and required staff assistance with most ADLs, including showering, dressing, toileting, and personal hygiene. A fall risk assessment showed a high fall risk score of 21. The facility’s Restraints policy defined physical restraints as any device that the resident cannot easily remove that restricts freedom of movement or access to one’s body, and required assessment, physician orders, informed consent, and care planning before use; the resident’s wrists being bound with a scarf was not associated with any such assessment, order, or care plan. On the night of the incident, the LVN heard the resident chanting in another language and asked the assigned CNA, who spoke the same language, what the resident was saying; the CNA responded that the resident always behaved that way. As the chanting became louder and more frequent, the LVN instructed the CNA to check on the resident. The CNA went into the room, spoke with the resident, and then left, telling the LVN that the resident was okay. When the chanting worsened, the LVN entered the room around 2:50 a.m., found the blanket on the floor, and upon picking it up observed the resident’s wrists bound with the scarf. After untying the scarf and assessing the resident with no visible injury noted, the LVN later found the CNA asleep and snoring at the nursing station; the CNA subsequently completed the shift and continued caring for the resident. The RMN later confirmed seeing the photograph of the resident’s hands tied on top of each other and stated that the LVN should have immediately reported the incident to the Administrator and immediately removed the CNA from the assignment and premises, but instead the reporting to leadership was delayed and the CNA remained on duty with the resident.
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