Failure to Fully Report Allegations of Resident Restraint to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to fully and accurately report an allegation of abuse involving the use of physical restraints on a resident by the resident’s developmental disability caregiver (DDC). On one morning, a staff member notified the ADON and DON that the resident was restrained to the bed. The ADON and DON then observed the resident’s arms tied to the bed rails with blankets, and the ADON removed the restraints. The incident report submitted to the state agency documented that the resident’s arms had been restrained by the DDC at that time and that the DDC was informed the facility did not allow restraints. However, during the subsequent investigation, it was learned that earlier that same morning, between approximately 6:30 AM and 7:00 AM, an LPN had already found the resident restrained with a sheet tied around the resident’s feet by the DDC, who stated he had done so because the resident was trying to kick the window. The LPN removed the sheet and told the DDC that the facility was restraint free. The LPN did not notify administration at that time, and this earlier restraint incident was not documented in the initial incident report or in the follow-up report submitted to the state agency. The Administrator confirmed that staff were expected to notify administration immediately of any concerns of abuse and that all allegations of abuse were expected to be reported to the state agency within two hours, but the facility did not notify the state agency about the earlier restraint episode involving the resident’s feet.
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