The resident called his family representative at 6 a.m. on September 28, saying he would call police because he was tied to the wheelchair. The family member lived close to the facility and drove there immediately.
He found the resident sitting in the dining room with a bedsheet wrapped around his waist and tied at the back of the wheelchair, restricting his movement. The nursing assistant was next to the resident working on the computer. The family representative demanded the aide untie the resident and reported the incident to a charge nurse.
The nursing assistant, identified as CNA 1, told inspectors the resident frequently got out of bed without asking for staff assistance during the night shift. The aide said the resident had a risk of falling and he also had to take care of other residents.
Around 5 a.m. on September 28, the nursing assistant decided to put the resident in the wheelchair. For the resident's safety, he wrapped the bedsheet around the resident's waist and "loosely tied it to the wheelchair so he could not stand on his own."
The aide acknowledged he should not have tied the resident to the wheelchair. He should have reported the resident's condition of getting out of bed to the charge nurse assigned to the resident.
At 6:30 a.m., a licensed vocational nurse was looking for the nursing assistant and found him in the dining room documenting on the computer with the restrained resident. The LVN saw the resident sitting in the wheelchair wrapped with the bedsheet covering the wheelchair.
She did not see if it was tied with a knot from where she was standing. The LVN reported the incident to the charge nurse assigned to the resident, which happened at the same time the family representative had reported to the charge nurse.
The LVN told inspectors she did not check if the resident was actually tied to the wheelchair with the bedsheet. She acknowledged she should have checked to make sure the resident was not tied with the bedsheet to the wheelchair.
The Director of Nursing was informed of the findings and acknowledged them during the October 9 inspection.
The use of physical restraints without proper authorization violates federal nursing home regulations designed to protect residents' rights and dignity. Restraints can only be used to ensure physical safety and must be the least restrictive intervention necessary.
Tying a resident to furniture with bedsheets constitutes an unauthorized physical restraint. The practice restricts the resident's freedom of movement and can cause psychological distress, as evidenced by the resident's call to his family representative threatening to contact police.
The incident occurred during the night shift when supervision may be reduced, but nursing assistants are still required to follow proper protocols for resident safety concerns. Rather than restraining the resident, the aide should have contacted the charge nurse about the fall risk and implemented appropriate interventions.
The nursing assistant's admission that he tied the resident to prevent him from standing demonstrates the restraint was intentional, not accidental. His acknowledgment that he should not have done it indicates awareness that the action violated facility policies and procedures.
The LVN's failure to investigate what she observed also represents a breakdown in the facility's oversight systems. Licensed staff have a responsibility to ensure unlicensed personnel follow proper care protocols and to intervene when they witness potential violations.
The family representative's quick response likely prevented the restraint from continuing longer. His immediate presence at the facility and demand for the resident's release suggests the restraint could have remained in place indefinitely without outside intervention.
Federal inspectors classified this as a violation with minimal harm or potential for actual harm affecting few residents. However, the psychological impact on the resident who felt compelled to threaten calling police indicates the restraint caused distress beyond the physical restriction of movement.
The incident highlights the challenges nursing homes face in balancing resident safety with freedom of movement, particularly during understaffed shifts. However, federal regulations provide clear guidance that restraints cannot be used for staff convenience or to address staffing shortages.
Terrace View Care Center must demonstrate how it will prevent similar incidents and ensure staff understand proper procedures for addressing resident safety concerns without resorting to unauthorized restraints.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Terrace View Care Center from 2025-10-09 including all violations, facility responses, and corrective action plans.