Improper Use of Pillowcase to Manage Resident Behavioral Symptoms
Penalty
Summary
The deficiency involves staff failing to demonstrate appropriate skills and competencies to meet a resident’s behavioral health needs. Resident B had diagnoses including cerebral palsy, severe intellectual disability, and muscular dystrophy, and a care plan dated 11/4/25 documented behavioral symptoms of hitting, kicking, and spitting at staff during care. The care plan interventions, initiated 11/4/24, directed staff that if the resident became resistive to care or combative, they were to postpone care and re-approach rather than continue in a confrontational manner. During an observation described by the Social Service Director (SSD), she entered Resident B’s room and saw CNA 2 and CNA 3 preparing to transfer the resident from bed to wheelchair while the resident’s entire face was covered with a pillowcase, though the head was not in the pillowcase. The SSD instructed the CNAs to stop and remove the pillowcase, after which they completed the transfer. CNA 2 told the SSD that the resident had spit at staff and she did not want to be spit on. The DON stated that CNA 2 and CNA 3 had access to the resident’s cardex with the appropriate interventions and should have known to use those interventions instead of covering the resident’s face with a pillowcase, contrary to the facility’s Behavior Management policy that calls for supportive, person-centered interventions for behavioral needs.
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