Failure to Protect Resident From Unauthorized Physical Restraint and Abuse
Summary
The deficiency involves the facility’s failure to protect a resident’s right to be free from physical restraints and abuse. A resident with dementia, Alzheimer’s disease, muscle weakness, gait and mobility abnormalities, and no capacity to make decisions was admitted in August 2025. The resident’s MDS dated 12/8/2025 showed severe cognitive impairment, with the resident rarely understanding and rarely being understood, and being dependent or requiring assistance for most ADLs. A fall risk assessment on the same date identified the resident as high risk for falls with a score of 21. These records established that the resident was cognitively impaired, physically vulnerable, and dependent on staff for care and safety. On the night in question, CNA 1 was assigned to the resident during the 11 p.m. to 7 a.m. shift and remained on duty until after 7 a.m. LVN 1 reported that around 2 a.m. the resident began chanting, which became louder and more frequent. LVN 1 asked CNA 1 to check on the resident; CNA 1 returned and stated the resident was okay and always behaved that way. Approximately 10 minutes later, the resident again began yelling in her own language. At around 2:50 a.m., LVN 1 entered the resident’s room, found the blanket on the floor, and observed the resident lying in bed making wiggly body movements. LVN 1 then saw that the resident’s wrists were firmly tied together in front of her with a long scarf, with no wiggle room and no ability for the resident to move or release her hands. LVN 1 untied the scarf and assessed the resident, noting no visible injury. The facility’s own policies required that any physical restraint be preceded by a licensed nurse’s assessment, IDT involvement, determination of need, identification of the least restrictive device, and appropriate documentation and consent. The restraint policy also stated that residents are to be provided a restraint-free environment and that restraints are not to be used for discipline or staff convenience. The abuse prevention policy stated that each resident has the right to be free from abuse, neglect, and mistreatment, that the facility has zero tolerance for abuse, and that staff accused of abuse, neglect, or mistreatment are to be suspended until the investigation is complete. The DON and Administrator both stated that tying the resident’s hands with a scarf constituted a physical restraint and physical abuse, and the Administrator indicated he believed CNA 1 tied the resident’s hands for the CNA’s convenience because the resident was restless. Despite this, CNA 1, who was suspected of tying the resident’s hands and was found sleeping during that time, was not immediately removed from duty and continued to provide care to the resident until the end of the shift, contrary to the facility’s abuse prevention policy.
Removal Plan
- LVN 1 reported the alleged abuse incident to Human Resources and the Director of Nursing, stating Resident 1 was found with hands bound by a scarf; LVN 1 removed the scarf and notified the Ombudsman.
- The facility suspended CNA 1 pending Human Resources investigation.
- LVN 1 received a written warning for failing to report the incident to the RN Supervisor on duty.
- The facility terminated CNA 1.
- The Director of Staff Development reported CNA 1 to the CNA Licensing Board.
- RN Supervisors conducted rounds on all units to visually observe all residents for any signs of physical restraints, inappropriate devices functioning as restraints, or signs of abuse/neglect; no other residents were identified.
- RN Supervisors conducted another facility-wide sweep of all residents to screen for restraints; no other residents were identified.
- Human Resources and the Administrator suspended LVN 1 for failure to follow facility policy.
- The Assistant Director of Staff Development initiated in-service training for facility staff regarding restraints, with the Assistant DSD and DSD continuing in-services until completion.
- During orientation, the facility will in-service newly hired staff on abuse and physical restraints, including review of the Abuse Prevention and Prohibition Program policy, resident rights, immediate reporting requirements, zero-tolerance policy and requirement to report suspected abuse immediately, and documentation requirements.
- The Director of Nursing created a root cause analysis.
- The Administrator and Director of Nursing instructed staff that there will be immediate removal of staff from duty when abuse/neglect is suspected.
- Shift-to-shift report will include reporting of any suspected abuse and immediate suspension of staff involved.
- Department Managers, Managers of the Day, and the RN Supervisor on duty will conduct daily rounds on every shift (including weekends and holidays) to validate no restraints observed weekly for four weeks, then monthly for two months, to ensure residents feel safe and are free from restraints.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with severe cognitive impairment, TBI, and dementia with behavioral disturbances used a one-piece jumpsuit identified as a restraint intervention to address genital exposure and related behaviors. The EMR showed consent and physician approval, but the quarterly MDS and care documentation did not show whether the garment remained needed, whether less restrictive alternatives had been tried, or whether restraint reduction or elimination had been considered. Staff interviews confirmed the resident had not worn the garment in a long time, and the DON stated there was no restraint-specific documentation form to track its use or reassess the need for it.
A resident with dementia and an amputated leg was dependent on staff for ADLs, transfers, and mobility. Staff twice placed a pillow along the resident's side under the fitted sheet after a mechanical lift transfer, and one NA stated the pillow was placed there so it would not fall out and that the resident could not easily remove it. RN staff and the DON stated pillows should not be placed under fitted sheets because that could be considered a restraint.
A resident with a history of wandering and elopement was moved from a room without a mesh gate to a room with a mesh gate on the door and was later observed yelling and unable to open the gate, which prevented exit from the room. A roommate reported that this resident often had difficulty opening the gate and called for help. The DON stated that residents who wander generally do not have mesh gates, that both roommates should be able to open any gate on their door, and that an assessment and care plan entry should exist for each resident using a mesh gate. The DON was unable to produce an assessment for this resident, confirmed the resident was not care planned for the mesh gate, and acknowledged that if an ambulatory resident cannot open a gate, it could be considered a restraint, contrary to the facility’s resident rights policy prohibiting restraints used for discipline or convenience.
A resident returned from the hospital with bilateral soft hand mittens in place, but staff did not obtain a physician’s order, informed consent, or complete required assessments and monitoring for restraint use. Facility records lacked any documentation of a medical symptom warranting restraints, a care plan, or scheduled removal and ROM exercises, despite policies requiring these elements. An LVN reported the resident arrived with mittens and that no consent or hand/wrist assessments were done, while another LVN stated she recognized the mittens as restraints without orders and said she told a CNA to remove them, which the CNA denied. The DON stated she was unaware of the mittens and confirmed that, per facility policy, any restraint use should have documented orders, consent, assessments, two-hour release for circulation checks, and a care plan.
Failure to Document and Assess Physical Restraint Use: Surveyors found that a bed placed against the wall for three residents and a pillow tucked under the sheets for one resident were used as restraints without the required MD order, informed consent, restraint assessment, or care plan. Staff, including RNs, LVNs, the DSD, and the DON, confirmed the positioning and stated these practices limited movement and were considered restraints, while the residents had diagnoses including weakness, impaired mobility, cognitive impairment, vision impairment, dementia, obesity, and other conditions affecting function.
A resident with bipolar disorder, dementia without behavioral disturbance, and anxiety, who was documented as alert, oriented, and independent in ADLs with intact cognition and no wandering behaviors, was initially assessed as not at risk for elopement and had a physician order permitting LOA with someone. Later, an LPN applied a Wanderguard to the resident’s ankle for reported exit-seeking, completed an elopement evaluation marking the resident at risk, but did not obtain consent from the resident’s conservator or document such contact, and the DON acknowledged that consent and less restrictive interventions should have preceded Wanderguard use. Despite the care plan subsequently labeling the resident an elopement risk and including Wanderguard use, the MAR and TAR did not show monitoring for wandering or exit-seeking behaviors, and the conservator later stated they had not been informed of prior exit-seeking, had not consented to the Wanderguard, and that the resident later described the facility as feeling like a jail.
Lack of Documentation for Ongoing Use of One-Piece Garment Restraint
Penalty
Summary
The provider failed to document whether one resident who used a one-piece jumpsuit as a restraint intervention was a candidate for restraint reduction, a less restrictive restraint method, or restraint elimination. The resident had severe cognitive impairment, a history of traumatic brain injury, and dementia with behavioral disturbances. He was observed seated in his wheelchair at breakfast and later in his recliner, repeatedly moving his feet, rocking his trunk, and placing his hand in and out of the waistband of his sweatpants. His EMR showed that the jumpsuit had been identified as a restraint intervention and that the resident's spouse had signed informed consent for its use. The record showed the resident had ongoing behaviors involving fondling himself and exposing his genitals, and staff requested physician approval for a one-piece garment to protect his dignity and prevent exposure to others. The physician approved the request. The quarterly MDS indicated the resident used a trunk restraint on a less-than-daily basis, and the MDS nurse's note stated that when available the resident would wear the one-piece jumpsuit. However, that assessment did not include documentation supporting continued use or discontinued use of the garment, and there was no indication that other alternatives had been tried. The behavioral tracking record documented other targeted behaviors, but fondling and exposing his genitals were not identified as targeted behaviors on that assessment. During interviews, an LPN stated the jumpsuit's zipper was on the backside of the garment, restricting the resident's access to his genitals, and said he had not worn it in a long time because of physical and cognitive decline. A CNA also stated she had not seen him wear the garment. The MDS nurse found the jumpsuit hanging in the resident's closet and acknowledged she did not know whether staff had completed restraint-related documentation. The DON stated there was no restraint-specific form to document when the jumpsuit was worn, what precipitated its use, what less restrictive interventions were tried, or how long it was worn, and acknowledged that without such documentation the quarterly assessment could not fully determine whether the jumpsuit remained needed or could be discontinued. The facility's restraint policy required least restrictive use, ongoing reevaluation, and quarterly review for restraint reduction, less restrictive methods, or elimination.
Pillow Placed Under Fitted Sheet Restricted Resident Movement
Penalty
Summary
The facility failed to ensure a resident was free from the use of a physical restraint when a pillow was placed adjacent to the resident's body underneath the fitted sheet, making it difficult for the resident to remove it independently. The resident, R44, had diagnoses of dementia and acquired absence of the right leg below the knee, and the quarterly MDS indicated the resident was dependent on staff for all ADLs, transfers, and mobility. R44's care plan identified impaired cognitive function/dementia, altered mood and behavior, and a history of putting self on the floor and crawling. The plan directed staff to keep the bed low and place a mat on the floor. During two separate observations, nursing assistants transferred R44 to bed using a mechanical lift, performed care, lowered the bed, and placed a pillow along the left side of the resident under the fitted bottom sheet. One NA stated the pillow was placed there so it would not fall out if the resident became agitated and did not think the resident could remove it. RN staff and the DON stated pillows should not be placed under fitted sheets because that could be considered a restraint, and one RN stated that if a resident could not easily remove a pillow and it prevented getting out of bed, it would be considered a restraint.
Failure to Prevent Use of a Physical Restraint Without Assessment or Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from physical restraints when not required for medical treatment. Resident #36 was care planned for wandering and elopement and had a history of attempting to elope. The resident was moved from a room without a mesh gate to a room with a mesh gate on the door. During observation, the resident was seen in their room yelling and unable to open the mesh gate, which prevented them from leaving the room. Another resident sharing the room reported that the roommate sometimes had difficulty opening the mesh gate and would call for help. The DON stated that some residents request mesh gates to keep out other residents who wander into their rooms and that both residents in a room should be able to access and open the mesh gate, with an assessment documented in the system and the gate included on the care plan. The DON acknowledged that residents who wander typically do not have mesh gates on their doors, that Resident #36 was not assessed for the use of the mesh gate when moved to the new room, and that there was no assessment documentation for this resident. The DON also confirmed that Resident #36 was care planned for elopement and wandering but not for the mesh gate, and that if an ambulatory resident could not open a gate, it could be considered a restraint. The facility’s Resident Rights Policy states that residents have the right to be free from physical restraints imposed for discipline or convenience and not required to treat medical symptoms.
Failure to Obtain Orders, Consent, and Monitoring for Use of Soft Mitt Restraints
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate use and management of physical restraints for one resident who was readmitted to the facility and returned from an acute care hospital with bilateral soft hand mittens in place. The facility’s own policies on a restraint-free environment and informed consent require that physical restraints only be used to treat a specific medical symptom, with a practitioner’s order, informed consent, and clear parameters for use, monitoring, and release. The policies also require that behavioral interventions be exhausted before restraints are used, and that informed consent be verified and documented by licensed nursing staff, except in documented emergencies. For this resident, medical record review showed no physician’s order, no signed informed consent, no assessment, no monitoring documentation, and no care plan addressing the use of the bilateral soft mitten restraints. There was also no documentation that the mittens were removed at regular intervals, that the resident’s hands and wrists were assessed, or that range of motion (ROM) exercises were performed every two hours as required by the facility’s policy. Medication Administration Records and shift assignment sheets identified LVN staff assigned to and administering medications to the resident during the period in question, but the records still lacked any restraint-related documentation. In interviews, LVN 1 stated the resident arrived with bilateral hand mittens and acknowledged being unaware of any informed consent and that the resident’s hands and wrists were not assessed while the mittens were on. LVN 4 reported that the resident returned to the facility with mittens, recognized them as restraints, and stated there were no orders for restraints, so she said she instructed a CNA to remove them; however, CNA 1 denied being instructed to remove the mittens and only recalled seeing the mittens in the resident’s closet. The DON stated she was unaware the resident was admitted with mittens and asserted that the facility does not use mittens, further stating that if a resident were admitted with soft mitten restraints, there should be documentation of physician orders, consent, assessments, two-hour removal for circulation checks, and a care plan. The Administrator and DON later acknowledged the findings identified in the review.
Failure to Document and Assess Physical Restraint Use
Penalty
Summary
The facility failed to ensure four sampled residents were free from the use of physical restraints without the required documentation and assessment for the restraint methods being used. The report identified restraint use as placing a bed against the wall for three residents and tucking a pillow under the sheets for one resident. For each of these residents, surveyors found missing or incomplete physician orders, informed consent, restraint assessments, and care plans related to the restraint use. Resident 142 was admitted with diagnoses including muscle weakness, difficulty walking, and glaucoma. The resident’s MDS showed moderate cognitive impairment, visual impairment, and need for partial assistance with mobility and ADLs. Surveyors observed the resident’s bed placed against the wall on the right side. The OSR did not show an order for the bed placement, and staff interviews confirmed that the bed against the wall was considered a restraint. RN 7, the DSD, and the DON each stated that a physician’s order, informed consent, restraint assessment, and care plan were required, and the DSD confirmed those elements were not present for this resident. Resident 264 had diagnoses including hemiplegia, hemiparesis, muscle weakness, and age-related nuclear cataract, with fluctuating decision-making capacity, highly impaired vision, moderate cognitive impairment, and dependence to partial assistance with mobility and ADLs. Surveyors observed the resident’s bed placed against the wall. The OSR did not show an order for the restraint, the BRERO did not include an assessment for bed placement against the wall, and staff stated there was no specific assessment for that positioning. The DSD and DON stated the resident did not have the required physician’s order, informed consent, restraint assessment, or care plan for the bed placement. Resident 86 had diagnoses including difficulty walking, cognitive communication deficit, history of falling, and unspecified dementia. The resident’s H&P indicated capacity to understand and make decisions, and the MDS showed the resident could make self-understood and understand others. Surveyors observed the resident’s bed against the wall on one date, and staff later reviewed a photo showing the same positioning. LVN 7 stated there was no assessment, consent, MD order, or care plan for the bed placement. Resident 80 had diagnoses including morbid obesity, depression, and venous insufficiency, with intact cognition and dependence to set-up assistance for mobility and ADLs. Surveyors observed a pillow tucked under the sheet at the right side of the resident, and LVN 1 stated this limited the resident to one side and was a form of restraint. The OSR did not show an order for pillows tucked under the sheets, and the DSD and DON confirmed the absence of a physician’s order, informed consent, restraint assessment, and care plan for that practice.
Unauthorized Use of Wanderguard Restraint and Inadequate Elopement Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from physical restraint and to obtain required consent from the resident’s conservator before applying a Wanderguard device. The resident had diagnoses of bipolar disorder, dementia without behavioral disturbance, and anxiety disorder, but on admission was documented as alert and oriented to person, place, time, and situation, verbally appropriate, and independent with all ADLs, bed mobility, transfers, and ambulation. An initial elopement risk scale completed at admission identified the resident as not at risk for elopement, and nursing notes and the MAR from admission through several days afterward did not document disorientation, verbalizations of wanting to leave, or exit-seeking behaviors. A physician’s order allowed the resident to go on leave of absence (LOA) with someone, and the admission MDS showed intact cognition (BIMS 15) and no wandering or behavioral symptoms. On a later date, LPN #1 documented that a Wanderguard was placed on the resident’s left ankle due to exit seeking and completed an elopement evaluation identifying the resident as at risk for elopement. However, the note did not indicate that the resident’s conservator of person had been contacted for approval prior to placement of the Wanderguard, and LPN #1 later stated she was unaware the resident was conserved and placed the device without contacting the conservator. The DON, who was the nursing supervisor that day, reported being aware that the resident wanted to leave and that the Wanderguard was applied, and acknowledged that the conservator should have been contacted for approval and that other interventions should have been attempted and documented before using a Wanderguard. Facility documentation, including the MAR and TAR, did not show monitoring for wandering or exit-seeking behaviors after the Wanderguard was applied, despite the care plan later identifying the resident as an elopement risk and including Wanderguard use as an intervention. Subsequently, the resident requested to go on LOA with a friend. At one point, an RN documented that the resident could not go on LOA because neither the resident nor the RN could reach the conservator. Later, a late entry note by another RN documented that the conservator consented to the LOA and that the resident left with a friend, with the LOA book signed. A further late entry note documented that the resident did not return from LOA as expected, attempts to contact the friend, the resident, the resident’s son, and the conservator were unsuccessful, and the police and facility leadership were notified; it was also noted that most of the resident’s belongings were gone. The conservator later reported that the facility had not obtained consent prior to placing the Wanderguard, had not reported prior exit-seeking or wandering behaviors, and that the resident later stated not wanting to return to the facility because it felt like a jail. The facility’s Wanderguard policy allowed placement when the care team decided a resident was at risk for wandering, but the facility did not provide requested policies on conservator notification and behavior monitoring.
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