A lawsuit alleges that instead of creating a plan to keep a 64-year-old resident from leaving and protect him from falling, a California nursing home used chemical restraints, which ultimately led to his death. The resident had leukemia and mild cognitive impairment and needed help with daily living and fall prevention.
According to the lawsuit his daughter filed in June 2024, staff knew that he was prone to wandering and wanted to leave the facility. Five days after he was admitted, he’d left the building and was found at a nearby crosswalk.
The lawsuit alleges that staff began using morphine and the sedative Ativan as chemical restraints, instead of creating a plan to keep the resident from leaving and to protect him from falling. The daughter claims that the medications used to keep him from wandering contributed to his death. She said they caused complications including disorientation, confusion, loss of balance, and susceptibility to falls.
Facility staff allegedly routinely administered morphine and Ativan to the resident without consulting his doctor as required under state regulations. Despite knowing the resident was at substantial risk of a life-threatening fall, the facility failed to create an effective prevention plan, and he died a few days after a fall, according to the lawsuit.
Compliance Perspective
Issue
Each resident should be free from chemical and physical restraints except as follows: when authorized in writing by a physician for a specified period of time; when necessary in an emergency to protect the resident from injury to the resident or to others, in which case restraints may be authorized by designated professional personnel who promptly report the action taken to the physician; and in the case of an intellectually disabled individual when ordered in writing by a physician and authorized by a designated qualified intellectual disabilities professional for use during behavior modification sessions. Mechanical supports used in normative situations to achieve proper body position and balance shall not be considered to be a restraint.
Discussion Points
- Review your policies and procedures for nursing services and other trained disciplines in providing quality care for residents, supervision and training of staff, and the use of restraints. Also review your policies and procedures for resident safety including fall prevention protocols and adequate monitoring to prevent elopement. Update policies as needed.
- Train staff regarding the importance of providing adequate monitoring and care for the residents, and the proper use of restraints. Establish a stop, look, listen care plan for residents at risk of falls. This means that any staff person passing the room should look into the room, listen for problems as they pass, even if it is not someone on their assignment that day and the resident has not called for assistance.
- Periodically audit to ensure that staff are aware of what constitutes a restraint, and that any restraint used on residents is authorized by a physician and for the specified period of time. Also periodically audit care plans to ensure that they are appropriate and contain evidence-based interventions to keep residents free from injury, that interventions are revised as needed, and that staff are informed of changes.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
