A nurse at St. Francis Nursing Center in Detroit ordered a nurse assistant to tie a highly agitated and confused resident to his chair with a bed sheet. An immediate jeopardy violation was issued to the facility for violating the resident’s right to be free from physical restraints for the purposes of discipline or staff convenience. Improper use of restraints puts a resident at risk for harm, serious injury, and even death.
This resident was highly agitated after being readmitted to the facility on May 25, 2012, following hip surgery. On May 27, 2012, the nurse assistant assigned to take care of the resident stated that he had gotten out of his bed a couple of times during the night and was crawling across the floor. In an attempt to monitor the resident, the nurse assistant placed the resident in a Geri chair and put him in the hallway. A Geri chair is often used in nursing homes for residents with mobility problems. Geri chairs recline and have a tray table attached at the front to keep the resident safe from falling forward.
During an interview with the inspector, the nurse assistant who tied the resident to the chair said that she found him out of his chair, on the floor, three times during her shift. The nurse assistant reported this to the nurse. The nurse then ordered the nurse assistant to use a bed sheet to tie the resident around the waist to the chair to prevent him from falling out again. The use of a bed sheet as a restraint is unsafe and never a recommended alternative to keeping a resident secure in a chair.
At the beginning of the next shift, a second nurse assistant spotted the resident tied to the chair, sitting in front of the nursing station. The second nurse assistant untied the resident and notified the Director of Nursing (DON), because she believed this to be a violation of the facility’s restraint policy. The DON asked the nurse assistant who tied the resident to the chair why it was done. The nurse assistant said the nurse was frustrated because the resident kept getting out of his chair. The nurse told the nurse assistant, “We have to do something. He keeps falling. It’s our license on the line.”
St. Francis’ restraint policy states: “Restraints will only be used after other alternatives have been tried unsuccessfully, and only with informed consent from the physician and/or the resident’s responsible party.” The nurse who ordered the resident to be restrained in his chair with a bed sheet failed to follow the policy. The nurse did not contact the resident’s physician, nor did she contact the DON, for further instruction. Additionally, the nurse did not note in the resident’s chart that a bed sheet was used as a bodily restraint. The nurse who ordered the resident to be tied to his chair was terminated on June 8, 2012 for violating the facility’s restraint policy and putting the resident at risk.
It was determined that the resident suffered no physical harm from being improperly tied to his chair. Facility administrators clarified the restraint policy to the staff, and stressed the importance of contacting the DON for guidance before making any changes in resident care.
Michigan Nursing Home Inspection Report
The Michigan Department of Licensing and Regulatory Affairs (LARA) conducts yearly inspections of nursing homes and long-term care facilities to ensure they are compliant with state and federal regulations.
Nursing home violations are documented in detail. Reports must be posted by the facility and made available to residents and family members. Serious violations are ones that put residents in immediate jeopardy. Inspectors who cite immediate jeopardy (IJ) violations will stay on site until the situation is resolved.