Failure to Report Alleged Staff Use of Unauthorized Physical Restraint
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of staff-to-resident abuse in the form of an unauthorized physical restraint to the State Survey Agency (DHSS). The facility’s abuse prevention policy states that residents have the right to be free from abuse, neglect, misappropriation of property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat medical symptoms. The policy also emphasizes that restraints are prohibited when used for discipline, convenience, or to unnecessarily inhibit a resident’s freedom of movement. Despite this, an incident occurred involving a resident with multiple mental health diagnoses and severe cognitive impairment, where staff actions constituted a restraint without an order or care plan, and the allegation was not reported to DHSS as required. Resident #2 had diagnoses including bipolar II disorder, anxiety disorder, personality disorder, epilepsy, and parkinsonism, with care plan interventions focused on managing socially inappropriate or disruptive behaviors through calm approaches, environmental modifications, reassurance, and communication strategies. The resident’s MDS showed severely impaired cognition but independence with mobility. On the day of the incident, the resident became upset in the business office after a phone call and while receiving printed pictures, escalating into a temper tantrum. According to NA B, when the resident began swinging their arms and hitting the aide on the head, the aide used prior behavioral health training to wrap their arms around the resident from behind, tucking the resident’s arms behind the mid-back and restraining the resident while walking them back to the unit, causing the resident to become upset and cry. Another CNA and an LPN described the resident’s hands being placed behind the back “like handcuffs” or “like being arrested” as the resident cried while being escorted. Multiple staff interviews showed that facility staff understood that physically restraining a resident, including holding arms down or behind the back, constituted a restraint and that any allegation of abuse or neglect, including physical restraint, must be reported immediately to the DON/Administrator and to the state within the required timeframe (one to two hours). CNA E reported the incident to the DON, and the DON acknowledged that aides reported the resident was irate and that NA B was restraining the resident by holding the resident’s arms. The DON and another nurse stated they ruled out abuse and neglect on their own and did not contact the state. Review of facility records and DHSS records confirmed there was no documentation of notification or self-report to DHSS regarding this allegation of abuse in the form of restraint use without an order, without a care plan, and for staff benefit, resulting in the cited deficiency for failure to timely report suspected abuse.
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