F0604

G

Unauthorized Physical Restraint Used on Behaviorally Challenging Resident

Lebanon, Missouri Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves staff physically restraining a resident by holding the resident’s arms behind the back while escorting the resident from the business office to the special care unit, contrary to facility policy and without a physician’s order. Facility policies on Resident Rights and Abuse Prevention state that residents have the right to be free from physical restraints except when used to treat a specified medical symptom as part of a total program of care, and that restraints must be authorized in writing by a physician or, in an emergency, by designated professional personnel with immediate notification to the physician. The policies also emphasize that residents must be free from abuse and that physical restraints are prohibited for discipline or staff convenience. In this case, there was no care plan for restraint use, no physician’s order for a physical restraint, and no documentation of restraint use in the resident’s record.

The resident involved had diagnoses including bipolar II disorder, anxiety disorder, personality disorder, epilepsy, and parkinsonism, with severely impaired cognition per the MDS. The care plan identified socially inappropriate or disruptive behaviors, difficulty understanding others, and disorganized thinking related to mental health issues and intellectual disabilities. Interventions included maintaining a calm environment, avoiding overstimulation, using calm and reassuring approaches, assessing for underlying needs, and allowing the resident to settle when upset. The resident’s progress notes described episodes of behavioral outbursts such as demanding immediate attention for medications or personal needs and occasionally throwing personal belongings, followed by later apologies, but did not include any plan or authorization for physical restraint.

On the day of the incident, a nurse aide (NA B) was in the business office with the resident during a Social Security call. After the call, NA B and the Business Office Manager (BOM) attempted to get the resident to return to the unit, but the resident refused and became increasingly upset. NA B reported that outside the business office the resident began swinging arms and hitting NA B on the head, at which point NA B wrapped arms around the resident from behind, placing the resident’s arms behind the mid-back to prevent further hitting, and maintained this hold while walking the resident back to the unit. Multiple CNAs who witnessed the event described NA B holding the resident’s arms and hands behind the back “like being arrested,” with shoulders raised, while the resident cried throughout the walk from the front area to the special care unit. Witnesses stated that the BOM walked beside them and attempted to calm the resident but did not stop the physical hold. The facility physician later stated that staff should not physically restrain residents without appropriate indications, confirmed there was no order for a physical restraint, and characterized the maneuver used by NA B as a physical restraint that was excessive and not acceptable.

The resident’s care plan and medical record contained no documentation authorizing or describing the use of this type of physical restraint for behavioral management. The quarterly MDS showed the resident was physically independent in transfers and walking, and there was no indication that a restraint was needed for mobility or safety support. The facility’s DON acknowledged that holding a resident’s hands behind the back “may or may not be considered abuse” and stated that the determination depended on intent and whether marks were left, but also acknowledged that staff had reported the incident as possible abuse. The DON and an LPN decided on their own that the incident did not constitute abuse or restraint and did not conduct an investigation into the allegation, despite staff reports that the resident was upset and crying and that the hold resembled an arrest-type restraint. No documentation was made in the resident’s progress notes about the restraint used when returning from the business office to the special care unit.