F0610

D

Failure to Investigate and Document Alleged Staff-to-Resident Restraint

Lebanon, Missouri Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that an allegation of staff-to-resident abuse/restraint was fully and timely investigated and that protective measures were documented and implemented during the investigation. Facility policy on Abuse Prevention, revised 11/28/16, states that residents have the right to be free from abuse, neglect, exploitation, involuntary seclusion, and any physical or chemical restraint not required to treat medical symptoms, and that the facility must take specific actions in response to alleged violations, including preventing further potential abuse while an investigation is in progress. Despite this policy, the facility did not complete or document a formal investigation after an incident in which a staff member physically restrained a resident.

The resident involved had been admitted with diagnoses including Bipolar II disorder, anxiety disorder, personality disorder, epilepsy, and parkinsonism, and had a care plan addressing socially inappropriate or disruptive behaviors, difficulty understanding others, and disorganized thinking related to mental health issues. The care plan directed staff to avoid overstimulation, maintain a calm environment and approach, assess whether behaviors endangered the resident or others, and use communication and environmental strategies such as speaking calmly, orienting the resident, and providing comfort measures. The resident’s MDS showed severely impaired cognition but independence with mobility, and progress notes described the resident as alert to self, autistic, occasionally having behavioral episodes when demands were not immediately met, sometimes throwing belongings, and later apologizing.

According to staff interviews, a nurse aide (NA B) was with the resident in the business office for a Social Security call, after which the resident refused to return to the unit and became increasingly upset when given printed pictures. NA B reported that outside the business office the resident began swinging arms and hitting NA B on the head, and NA B responded by wrapping arms around the resident from behind, under the resident’s arms, with the resident’s arms tucked behind mid-back, restraining the resident while walking back to the unit, which caused the resident to cry. Another CNA witness stated that the resident should not have been taken off the locked unit, observed NA B yelling at the resident, then getting behind the resident and holding the resident’s arms behind the back “like being arrested,” with the resident crying while being walked in this position, and noted that the BOM walked beside them and attempted to calm the resident. The CNA reported the incident to the DON. The DON later acknowledged that no investigation was completed and that he and an LPN had personally “ruled out” abuse and neglect without a written investigation, and the administrator stated she would have expected a written investigation and that it was the DON’s or her responsibility to determine if it was an abuse situation. No written investigation or documented protective steps were provided for review.