Failure to Individually Assess and Care Plan Use of Restraints and Alarms
Summary
The deficiency involves the facility’s failure to ensure residents were free from physical restraints unless needed for medical treatment, and to follow required assessment, ordering, care planning, and monitoring processes for restraints. Surveyors found that three residents with significant neurological conditions and cognitive impairment were routinely provided lap belt alarms, bed alarms, side rails, and wander guard devices without individualized assessment of medical symptoms, evaluation of less restrictive alternatives, or clear documentation of ongoing re-evaluation. The facility’s own restraint policy required an interdisciplinary assessment, informed consent, a physician order specifying medical symptoms and circumstances of use, and periodic re-evaluation, but requested documentation of these elements for the three residents was not provided. For one resident with a CVA, significant cognitive impairment (BIMS 6), hemiplegia, impaired mobility, and multiple neurologic deficits, surveyors observed bilateral quarter side rails at the head of the bed, three-quarter side rails at the foot of the bed, a seat belt alarm in the wheelchair, and a wander guard bracelet attached to the wheelchair. The resident could not state the purpose of the side rails, could not remove the lap belt independently, and spoke incoherently. The physical device assessment stated the side rails did not restrict freedom of movement and that the resident understood risks and benefits, listed symptoms such as weakness, impaired mobility, impulsive movements, and cognitive deficits, and documented no less restrictive devices tried. The admission MDS showed significant cognitive impairment and need for moderate assistance with mobility and ADLs. The care plan referenced half side rails for positioning and safety due to spasms and a seat belt alarm for trunk support, but did not address the foot-end side rails, did not specify when staff should release the belt, and did not include the wander guard or related interventions. For a second resident with a CVA, severe cognitive impairment (BIMS 0), aphasia, dysphagia, hemiplegia, and dependence or high assistance needs for mobility and ADLs, surveyors observed bilateral quarter side rails, a seat belt alarm in the wheelchair, and a wander guard bracelet attached to the wheelchair. The resident was unable to move the right arm, could not remove the lap belt independently, and communicated only by nodding. The physical device assessment indicated the resident could use the side rails appropriately, that they did not restrict movement, that the decision maker understood risks and benefits, and that no less restrictive devices were tried. The admission MDS documented severe communication and cognitive deficits and extensive assistance needs. However, the care plan did not include the side rails, seat belt alarm, or wander guard, and contained no interventions related to these devices. For a third resident with a CVA, hemiplegia, dysphagia, aphasia, gait abnormalities, and other cognitive signs but a cognitively intact BIMS score of 14, surveyors found quarter side rails, a bed alarm, and a seat belt alarm. The resident reported being fine with the wheelchair belt and alarm but stated he did not consent to the bed alarm, that it startled him, made him feel unable to move freely in bed, interfered with sleep, and caused concern about disturbing nearby residents. The physical device assessment documented quarter side rails for turning and repositioning, stated the resident could use them appropriately and that they did not restrict movement, but noted that the resident and decision maker did not state they understood risks and benefits, and again showed no less restrictive devices tried. The care plan listed a bed alarm, seat belt alarm for trunk support, and grab bars/bedrails, but did not address the resident’s expressed objection to the bed alarm. Staff interviews revealed that lap belts, side rails, and bed alarms were applied as a standard practice for residents with brain injuries upon admission, rather than based on individualized assessments. Nursing assistants reported they had never been instructed to release lap belts routinely, and that belts for the three residents were only removed for toileting or at bedtime; one aide stated a resident did not understand the purpose of the belt and frequently removed it when agitated. Therapy staff and nurses stated that all residents with brain injuries received lap belts and side rails on admission, with therapy later assessing appropriateness, and described the devices as necessary for safety, impulsiveness, and fall prevention. The NP acknowledged signing orders based on therapy assessments, was unsure what assessments were performed, and did not know whether less restrictive alternatives were attempted or how monitoring occurred. The DON and Administrator confirmed that lap belts, bed alarms, and side rails were considered standard safety practice for this population, while the Medical Director stated she was not aware that these devices were automatically applied on admission and indicated that if a resident felt restricted by a bed alarm, alternatives should have been tried. The facility’s written restraint policy stated that residents have the right to be free from physical restraints, that positioning and safety devices must be determined through individual interdisciplinary assessment and care planning with resident consent and physician order, and that physical restraints are defined as devices attached or adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body. The policy required informed consent, documentation of risks and benefits, physician orders specifying medical symptoms and circumstances of use, and periodic re-evaluation. Despite this, when surveyors requested documentation for the three residents regarding medical diagnoses and symptoms supporting restraint use, evaluation of alternatives, and device inspections, the facility did not provide the requested records, demonstrating a failure to implement the policy’s required processes for assessment, determination of medical symptoms, consideration of less restrictive alternatives, and ongoing re-evaluation of restraint use for these residents.
Penalty
Resources
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Body pillows were used as restraints for three residents with significant cognitive and mobility impairments. Staff placed body pillows under sheets or tightly against the bed to keep residents in bed or prevent them from removing the pillows, and an NA stated this was done so a resident would not try to get out of or roll out of bed. The LPN and DON stated that placing body pillows this way made them a restraint.
Failure to assess whether a mattress bolster was a restraint for a resident with dementia, anemia, and HTN. The resident’s care plan included bolsters to bed for fall risk, and staff observed the resident in bed with bilateral raised mattress edges, but the record had no assessments or ongoing evaluations of bolster use. A UM confirmed the facility did not assess the resident’s functional status to determine whether the bolster was a restraint.
Improper Use of Roll Bolster as a Physical Restraint: A resident with dementia and severe cognitive impairment was observed with a Roll Bolster secured along the side of the bed, limiting the ability to sit up, stand, or get out of bed independently. Staff stated it was being used to prevent the resident from rolling over and exiting the bed, but there was no physician order, no documented use of alternative measures, no informed consent from the responsible party, and no care plan for the device. The facility policy identified such a device as a physical restraint when it restricts movement.
A resident with epilepsy and profound intellectual disabilities remained in a padded wheelchair with a lap belt and helmet, but staff did not release the belt during supervised care and meals. The DON stated the belt should be released when supervised and at least every two hours, yet the restraint reduction assessment was copied from an older date and staff said they had not tried to reduce the restraint because the resident’s epilepsy had not changed.
Failure to Complete Quarterly Restraint Reassessments: A resident with quadriplegia, muscle weakness, and impaired mobility used a wheelchair seat belt and lap tray, and observations showed both devices in place while the resident was in a power wheelchair. Although the care plan addressed the seat belt and noted the resident could independently lock and release it, the EMR showed the last restraint quarterly assessment was completed months earlier, with no later reassessment documented. RN and DON interviews confirmed the quarterly reassessment was expected but had not been completed.
A resident with intact cognition and behavioral symptoms including paranoia, hallucinations, and attempts to leave the building became highly agitated, pulled fire alarms, entered other residents’ rooms, and handled a fire extinguisher. Video and staff statements showed an LPN/CNA physically held the resident by the wrist, waist, and back while escorting the resident to the room, despite no order authorizing restraint and the resident not consenting to the contact.
Body pillows used as restraints
Penalty
Summary
The facility failed to ensure body pillows used as positioning devices were not implemented as physical restraints for 3 of 3 residents reviewed for restraints. R5 had diagnoses including a right femur fracture, osteoarthritis, dementia, osteoporosis, and a history of falling. After a witnessed fall, staff placed a body pillow under the sheets to prevent further self-ambulation, and the fall care plan was revised to include the body pillow under the sheets. R5 later had another incident in which she was found on the floor at the foot of the bed after family had placed her in bed without staff assistance. R11 had diagnoses of hemiplegia and hemiparesis affecting the left side and dementia. Her fall review identified her as at risk for falls due to scheduled narcotics, psychotropics, bowel and bladder incontinence, and being alert but unaware of mobility limitations. Her care plan included a body pillow for repositioning when in bed. During observation, staff placed a body pillow between R11 and the side of the bed underneath the sheet and tucked it securely into place, and the NA stated the body pillow was used to keep R11 in bed. R10 had diagnoses of hemiplegia and hemiparesis following cerebral infarction. Her MDS identified moderate cognitive impairment, daily physical and verbal behaviors, daily rejection of care, and need for substantial to maximum assistance with bed mobility and transfers. Her care plan included body pillows to outline the mattress parameter. During observation, a body pillow was tucked under the mattress sheet on the side of the bed, and the NA stated it was placed tightly so R10 would not remove it and so he would not attempt to get out of or roll out of bed. The nurse manager and DON stated body pillows should never be placed under the sheets to keep residents from getting out of bed and that doing so made the body pillow a restraint.
Failure to Assess Mattress Bolster as a Possible Restraint
Penalty
Summary
The facility failed to assess the functional status of Resident R23 to determine whether the use of a bolster on the mattress was a restraint. Facility policy defined physical restraints as any method or device attached to or adjacent to the resident’s body that the individual cannot remove easily and that restricts freedom of movement or normal access to the body. Resident R23’s record showed admission to the facility, diagnoses of high blood pressure, dementia, and anemia, and a physician order for a bolster mattress to bed dated 12/23/24. Resident R23’s care plan identified the resident as high risk for falls related to confusion, psychoactive drug use, a history of a fall at home with left hip fracture, and poor balance and safety awareness, with interventions including bolsters to bed when in bed. During observation on 6/23/26 at 9:47 a.m., Resident R23 was lying in bed with a mattress that had bilateral raised edges on the top and bottom portions. The clinical record did not identify any assessments or ongoing evaluations for the use of bolsters on the resident’s mattress, and a Unit Manager confirmed on 6/26/26 at 9:26 a.m. that the facility failed to assess whether the bolster was a restraint for the resident.
Improper Use of Roll Bolster as a Physical Restraint
Penalty
Summary
Resident 67 was observed with a Roll Bolster secured to the left side of the bed, extending from the shoulder to the lower extremities and restricting the resident’s ability to sit up, stand, or reposition independently. The resident was admitted with diagnoses including dementia, fracture of the left humerus, and muscle wasting, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated severely impaired cognitive skills and moderate assistance was needed with ADLs. The facility used the Roll Bolster to prevent the resident from getting out of bed and rolling over, but the record review found no physician order for the device, no documented evidence that alternative measures were used before it was placed, and no informed consent from the responsible party. During interviews, staff stated the bolster was being used to keep the resident from getting out of bed, and the DON confirmed there was no documented physician order, no informed consent, and no care plan developed for the use of the Roll Bolster. The facility’s policy stated that any mechanical device attached to or adjacent to a resident’s body that restricts freedom of movement is a physical restraint and requires a physician’s order, informed consent, documentation, care planning, ongoing monitoring, and periodic reevaluation. The RDCO stated that if the bolster inhibits the resident’s ability to get out of bed, it is considered a restraint, and the DON stated staff should have obtained a physician’s order, consent, and notified the resident or responsible party before placing any restraint.
Failure to Reduce and Release Wheelchair Lap Belt
Penalty
Summary
The facility failed to attempt a reduction of a resident’s restraint and failed to release the restraint when the resident was supervised. Resident R3 had diagnoses including epilepsy, profound intellectual disabilities, dysphagia, osteoporosis, and acute kidney failure, and was using a lap belt while seated in a padded wheelchair along with a protective helmet. During observation at lunch, R3 remained in the wheelchair with the seatbelt in place while staff removed the helmet and assisted with feeding; the seatbelt was not released during the supervised meal. Staff stated the helmet is removed at lunch and that the new padded wheelchair was helping with positioning, and they reported that R3 rarely scoots anymore and only needed repositioning once earlier. Record review showed the restraint reduction assessment was dated 10/7/25 and stated R3 continued to require the lap belt because of poor trunk control, spastic involuntary movements, and seizures, with the belt released under direct supervision and by the resident’s mother. The progress notes from 1/1/26 through 6/23/26 did not show any falls from the padded reclining wheelchair. The DON stated the seatbelt should be released at least every two hours and when R3 is supervised, but also stated the assessment had been copied and pasted and that R3’s epilepsy diagnosis had not changed, so they had not tried to reduce the restraint. The care plan stated R3 needed the lap belt and helmet when left unattended in the wheelchair, and the facility policy required the need for a restraint to be re-evaluated at least quarterly with efforts made to eliminate continued use.
Failure to Complete Quarterly Restraint Reassessments
Penalty
Summary
The facility failed to ensure ongoing assessment and evaluation of physical restraints for a resident who used a wheelchair lap tray and seat belt. The resident had intact cognition and diagnoses including quadriplegia, muscle weakness, lack of coordination, and abnormalities of gait and mobility. The quarterly MDS dated [DATE] identified that the resident did not use restraints, yet observations on 6/22/26 and 6/25/26 showed the resident seated and propelling in a power wheelchair with a secured seat belt and lap tray in place. The resident’s care plan dated 5/11/26 identified the seat belt use, noted the resident could lock and release it independently, and stated the resident had been educated on risks versus benefits and signed consent for use. The Physical Restraint Quarterly Assessment history showed the most recent assessment was completed on 2/17/26, and the EMR lacked evidence of any additional quarterly restraint assessments after that date. RN-A stated the nurse manager was responsible for reassessing continued need and ability to use the devices. The RNCM confirmed the assessment should have been completed after 2/17/26 and stated it had not triggered in the EMR system. The DON also confirmed another assessment should have been completed after 2/17/26 and stated quarterly assessments were expected to determine continued need, independent removal ability, and whether alternative interventions were needed.
Physical restraint used during behavioral episode
Penalty
Summary
The facility failed to keep a resident free from physical restraints during a behavioral episode. Resident #1 had a BIMS score of 13, indicating intact cognition, and diagnoses that included hypertension, arthritis, and COPD. The resident’s care plan documented paranoia, negative statements, medication and care refusals, attempts to leave the building, calling the police, hallucinations, and delusions, with interventions focused on reassurance, leaving and returning later, calm communication, diversion, and protecting other residents by removing the resident to another location. During the overnight incident, Resident #1 pulled fire alarms, entered other residents’ rooms, screamed for help, ripped a telephone off the wall, destroyed it, and grabbed a fire extinguisher and aimed it at residents and staff. Staff reports and video evidence showed that Staff B approached Resident #1 from behind, placed an arm around the resident’s back, held the resident’s wrist, and secured the resident’s waist while escorting the resident back to the room. The report states that Resident #1 did not consent to the physical contact and could not disengage, and that the hold continued as the resident was guided down the hallway and into the room. Staff statements described the contact as an attempt to prevent a fall or calm the resident, but the facility’s own restraint-free policy defined physical restraint to include holding down a resident in response to behavioral symptoms or during care when the resident resists or refuses care. The record review found no order authorizing staff to physically restrain Resident #1. Interviews with staff and the DON confirmed that the facility did not consider physical restraints acceptable practice, yet the documented actions during the incident included holding the resident by the wrist, waist, and back while the resident resisted, lowered to the floor, and refused to stand.
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