SUMTER, SC - Federal inspectors determined that Sumter East Health & Rehabilitation Center failed to protect a vulnerable resident from physical restraint, resulting in an immediate jeopardy citation during a complaint investigation completed March 20, 2025.
The incident involved a resident with bilateral below-the-knee amputations and end-stage renal disease who reported being physically restrained by a certified nursing assistant during nighttime care. According to the inspection report, the nursing assistant admitted to holding the resident's hands down against his upper chest and neck area while providing incontinent care.
Vulnerable Resident Placed at Risk
The resident, identified in the report as R1, had been admitted to the facility in June 2024 with multiple serious medical conditions including respiratory failure with hypoxia, dependence on renal dialysis for end-stage renal disease, peripheral vascular disease, and bilateral below-the-knee amputations. The resident also had a dialysis catheter placed in his right upper chest area.
Assessment data from January 2025 showed the resident was cognitively intact, scoring 15 out of 15 on the Brief Interview for Mental Status. His care plan documented self-care deficits related to activities of daily living, impaired mobility, muscle weakness, lack of coordination, pulmonary edema, and incontinence of bowel and bladder. He also required oxygen therapy for acute and chronic congestive heart failure, restrictive lung disease, and cardiomyopathy.
Details of the Physical Restraint Incident
The incident occurred during the overnight shift on March 2, 2025. According to the resident's account to facility staff, the nursing assistant entered his room after he activated his call light. The resident stated that the CNA "just started hitting my stumps," referring to his amputation sites. He noted that his left amputation site remained tender as it had not been long since the surgery.
When the resident activated his call light again, the nursing assistant returned and "grabbed me and held my hands down around the upper part of my chest," the resident reported. He explained that he was frightened the assistant would dislodge his dialysis catheter, so he stopped resisting. The resident stated unequivocally: "I never hit him or pushed him. I could not believe he was doing me like that."
The nursing assistant's written statement contradicted the resident's account. In his statement, the CNA wrote: "Resident put on his call light, I, myself went in and asked what was wrong and he said he needed a brief change... the resident started to whine. His CNA for the night was falling behind so I went in his room and told him I was going to change him and he swung at me so I restrained him until he cooled down."
During an interview with facility leadership, the nursing assistant confirmed his actions. According to the Director of Nursing's statement in the report, the CNA "had informed the DON that he grabbed both of the resident's hands and with one of his hands, he held them down across R1's upper chest and neck area." The assistant told the DON: "I had no choice but to restrain him."
Medical and Safety Implications
Physical restraint of residents in nursing homes creates multiple risks, particularly for medically fragile individuals. For a resident with a central venous catheter used for dialysis access, any physical force applied to the upper chest area poses serious risks of catheter dislodgement, infection, or vessel injury.
Dialysis catheters are typically tunneled beneath the skin to provide stable vascular access for patients with end-stage renal disease. These devices require careful handling and protection from trauma. Dislodgement or damage to a dialysis catheter can result in emergency situations requiring immediate medical intervention, potential loss of vascular access, bleeding complications, and interruption of life-sustaining dialysis treatments.
For residents with recent amputations, pain and sensitivity at surgical sites remain elevated during the healing process. Physical contact with amputation sites can cause significant discomfort and potentially interfere with proper healing. The resident's report that his left amputation remained tender underscores the vulnerability of his physical condition.
Federal regulations prohibit the use of physical restraints except in extremely limited circumstances where they are medically necessary and properly authorized. The facility's own policy stated that physical restraints refer to "any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove and restricts freedom of movement." The policy specifically included "holding down a resident in response to behavioral symptoms, during the provision of care if the resident is resistive or refusing the care" as a form of physical restraint.
Staff Response and Investigation
The resident reported the incident immediately when the day shift Licensed Practical Nurse arrived on March 2, 2025, at approximately 7:15 AM. According to the nurse's statement, the resident was "very upset and it took a few minutes to calm him down." The resident was "adamant about calling his family and wanting to press charges against the CNA."
The facility's Director of Nursing responded by 7:45 AM, contacting the nursing assistant by phone and immediately suspending him. The DON interviewed the nursing assistant, during which he admitted restraining the resident. At 8:04 AM, the facility reported the allegation to the South Carolina Department of Public Health as required by law.
The DON conducted a physical examination of the resident at 8:30 AM, completing a body audit that found no marks or bruises. During this interview, the resident demonstrated how his legs naturally point upward due to his amputations when lying on his back, and showed how the nursing assistant had crossed his arms on his upper chest and held them down.
Local police authorities were notified at 9:30 AM. Officers responded, took statements, and filed a report. The resident's attending physician was notified, and the resident's family was contacted that morning.
Facility's Corrective Actions
Following the immediate jeopardy determination, the facility implemented several corrective measures on March 20, 2025. The Staff Development Coordinator began providing mandatory education to all staff regarding restraints, including specific training that holding a resident's hands down constitutes physical restraint.
The facility mandated that all staff complete restraint training before being allowed to work. The training was incorporated into new hire orientation and scheduled for annual refresher courses. The facility committed to monthly audits of new hire orientation packets for six months, followed by quarterly audits, to ensure all employees receive proper training on restraint policies.
The Social Services Director monitored the affected resident for ongoing psychological effects and reported no lasting trauma, with the resident expressing relief that the nursing assistant no longer worked at the facility. Interviews with other residents found no pattern of similar incidents.
The facility's Quality Assurance and Performance Improvement committee held an emergency meeting on March 20, 2025, with the Medical Director participating by phone. The committee reviewed the incident response and approved the addition of restraint training as a focus area for both new hire orientation and annual continuing education.
Regulatory Context and Industry Standards
The citation issued under F604 addresses the requirement that nursing homes provide care that maintains or enhances each resident's quality of life and ensures residents are free from physical restraints imposed for purposes of discipline or convenience. When facilities use restraints improperly, they face citations for providing substandard quality of care.
Federal guidelines establish that physical restraints may only be used when medically necessary to treat a resident's medical symptoms, must be ordered by a physician, and require detailed documentation and monitoring. Using physical force to control a resident's behavior during care provision violates these standards.
The immediate jeopardy designation indicates that the facility's practice created a serious threat to resident health or safety requiring immediate corrective action. This represents the most serious category of nursing home deficiency, signaling that residents faced or could have faced serious injury, harm, impairment, or death.
Nursing home residents maintain the right to be free from abuse, neglect, and exploitation. This includes protection from physical handling that restricts movement or causes fear, regardless of staff justifications about resident behavior or care efficiency.
For complete details of the inspection findings and facility response, readers can access the full Centers for Medicare & Medicaid Services inspection report through official channels.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sumter East Health & Rehabilitation Center from 2025-03-20 including all violations, facility responses, and corrective action plans.
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