MANDAN, ND - A registered nurse at Sunset Drive - A Prospera Community was terminated in June 2024 after an investigation revealed improper use of physical restraints on a resident, prompting facility-wide staff retraining on restraint protocols and abuse reporting procedures.
Unauthorized Restraint Application Leads to Employee Termination
During a June 2024 state inspection at Sunset Drive, investigators documented that a nurse failed to follow established facility policy when implementing a restraint on a resident. The incident, which occurred on June 7, 2024, resulted in the nurse being placed on administrative leave two days later while the facility conducted an internal investigation.
According to the inspection report, the nurse's actions violated federal regulations governing the use of physical restraints in nursing facilities. These regulations exist to protect residents from unnecessary physical restrictions that can lead to both physical harm and psychological distress. The investigation concluded on June 17, 2024, when the facility terminated the nurse's employment.
The incident also revealed gaps in the reporting chain, as two certified nursing assistants (CNAs) who were present during the event failed to immediately report the improper restraint use to supervisory staff. Federal regulations require nursing home employees to report any witnessed violations of resident rights or potential abuse situations to appropriate supervisory personnel without delay.
Medical and Safety Implications of Improper Restraint Use
Physical restraints in nursing facilities must meet strict criteria before implementation. Under federal guidelines, restraints can only be applied when necessary to treat a resident's medical symptoms and when less restrictive interventions have proven ineffective. Even when medically justified, restraints require a physician's order that specifies the type of restraint, duration of use, and circumstances requiring application.
Improper restraint application presents multiple health risks to nursing home residents. Physical complications can include circulation problems in restrained limbs, pressure injuries from prolonged contact with restraint devices, increased fall risk when residents attempt to remove restraints, respiratory complications if restraints restrict chest movement, and muscle weakness or contractures from reduced mobility.
Beyond physical consequences, unauthorized restraints can cause significant psychological harm. Residents may experience increased anxiety, depression, agitation, and feelings of helplessness. Research in geriatric care has documented that inappropriate restraint use can accelerate cognitive decline in residents with dementia and create traumatic stress responses, particularly in individuals with histories of trauma or abuse.
The incident at Sunset Drive highlighted the critical importance of proper restraint protocols. When restraints are necessary, nursing staff must follow specific procedures including obtaining proper authorization, documenting the medical necessity, monitoring the resident at frequent intervals, regularly releasing the restraint to allow movement and circulation, and continuously reassessing whether the restraint remains necessary.
Facility Response and Corrective Measures
Following discovery of the violation, Sunset Drive implemented a comprehensive corrective action plan to address both the specific incident and prevent future occurrences. The facility's response demonstrated recognition of the severity of the violation and the need for systematic changes to staff training and oversight.
Immediate Actions: The facility placed the involved nurse on administrative leave within two days of the incident to protect residents during the investigation period. After completing the investigation, management terminated the nurse's employment on June 17, 2024. The two CNAs who witnessed but failed to promptly report the incident received immediate re-education on abuse and neglect reporting requirements during their interviews on June 9, 2024.
Staff Education Initiatives: Management required all nursing staff to review a comprehensive "Proper Use of Restraints" PowerPoint presentation, with completion required by June 14, 2024. The facility disseminated this training material to all units, requiring staff acknowledgment of review. Additionally, the facility reassigned all employees to complete an "Abuse and Neglect of the Vulnerable Adult" training module through their online Success Center learning platform, with a completion deadline of July 15, 2024.
Policy Implementation: The corrective action plan included mandatory training requirements for all new hires, who must now complete the abuse and neglect training module and review the restraint use presentation as part of orientation. The facility scheduled all-staff meetings for June 25, 2024, at both 7:00 a.m. and 2:30 p.m. to review abuse and neglect policies and reporting expectations with all employees across all shifts.
Reporting Requirements and Chain of Command Failures
The incident exposed a significant gap in the facility's reporting culture. The two CNAs present during the improper restraint application did not immediately notify supervisory staff of the violation. Federal regulations require nursing home employees to report suspected violations of resident rights, potential abuse situations, or departures from established care protocols to appropriate supervisory personnel as soon as possible.
The facility's re-education of the CNAs emphasized the importance of timely reporting to either the on-call nurse or the Director of Nursing when witnessing incidents that may compromise resident safety or rights. This reporting requirement exists to ensure prompt intervention, protect other residents from potential harm, and allow management to investigate and address problems before they escalate or recur.
Effective reporting systems in nursing facilities depend on multiple factors. Staff must understand what constitutes reportable behavior, know the proper channels for reporting concerns, feel confident that reporting will not result in retaliation, and recognize that timely reporting protects both residents and the facility from harm.
Regulatory Framework for Restraint Use
Federal regulations governing nursing home operations establish strict parameters for physical restraint use. These rules reflect decades of research demonstrating that restraints, once commonly used in elder care settings, often cause more harm than they prevent. The regulations require that restraints may only be imposed to ensure the physical safety of the resident or other residents, and only when less restrictive interventions have been determined ineffective.
Before applying any restraint, facilities must conduct thorough assessments to identify the underlying cause of behaviors that might prompt restraint consideration. Alternative interventions might include modifying the environment to reduce confusion or agitation, adjusting medication regimens that may contribute to behavioral symptoms, increasing supervision or redirecting attention, addressing underlying medical conditions causing discomfort, or implementing individualized activity programs to reduce anxiety.
When restraints become necessary, documentation requirements include physician orders specifying the type and duration of restraint, assessment notes explaining why less restrictive measures proved inadequate, monitoring records showing regular checks of the restrained resident, and ongoing evaluation of whether the restraint continues to be necessary.
Industry Standards and Best Practices
The nursing home industry has moved toward restraint-free care models over the past several decades. Research has demonstrated that facilities can maintain resident safety while dramatically reducing or eliminating restraint use through comprehensive staff training, environmental modifications, and individualized care approaches.
Best practices in modern nursing home care emphasize understanding the underlying causes of behaviors that might traditionally have prompted restraint use. Residents with dementia, for example, may exhibit wandering or agitation due to unmet needs such as pain, hunger, need for toileting, overstimulation, or boredom. Addressing these underlying needs often eliminates the behaviors without requiring physical restrictions.
Facilities with successful restraint-reduction programs typically implement specialized staff training in dementia care and behavioral management, environmental modifications to support safe mobility, increased staffing levels to allow closer supervision, comprehensive pain management protocols, and individualized activity programs tailored to resident interests and abilities.
Additional Issues Identified
The inspection documented that the facility recognized the deficient practice existed on June 7, 2024, and implemented corrective action by June 14, 2024. State surveyors determined that the violation represented minimal harm or potential for actual harm, affecting few residents. The facility's swift response and comprehensive corrective action plan addressed both the immediate situation and systemic factors that allowed the violation to occur.
The inspection classified the violation as past non-compliance, indicating that the facility had already implemented effective corrective measures by the time of the survey. This classification reflects the facility's proactive response to the incident and the thoroughness of their corrective action plan.
The facility continues to monitor restraint use practices and maintain ongoing staff education to ensure compliance with federal regulations and protection of resident rights. The implementation of mandatory annual training on abuse and neglect, combined with enhanced reporting protocols and new hire orientation requirements, demonstrates the facility's commitment to preventing similar incidents in the future.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sunset Drive - A Prospera Community from 2024-06-19 including all violations, facility responses, and corrective action plans.
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