Health inspection·April 10, 2025

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to protect residents' right to be free from physical restraint for 1 (Resident #1) of 1 resident reviewed for restraints. Residents Affected - Few The findings included: Review of the clinical record revealed Resident #1 was re-admitted to the facility on [DATE]. Diagnoses included Traumatic Subdural Hemorrhage (bleeding in the brain), Aphasia (language disorder affecting ability to speak) following Cerebral Infarction, and muscle weakness. The admission Minimum Data Set (MDS) assessment with a target date of 11/12/24 noted the resident's cognition was severely impaired with a Brief Interview for Mental Status score of 05. Review of the facility's incident investigations revealed on 11/25/24 at 7:45 a.m., the Director of Rehab reported to the Administrator when the Certified Occupational Therapist Assistant (COTA) went to get Resident #1 for therapy, she found the resident in his room, in his wheelchair with a sitter. The resident had a gait belt around his abdomen and secured to the back of the wheelchair. The resident was assessed and there were no injuries. The investigation noted Resident #1's sitter said in an interview that she was assigned to provide one to one supervision to Resident #1 during the alleged incident. She said she had been assigned to the resident for a double shift starting at 10:00 p.m. She said Resident #1 for up at around 5:00 a.m. Resident #1 kept getting up. The therapist came by and said she would be right back to bring the resident to therapy. The sitter said she put the gait belt on because Resident #1 kept getting up. She said she was holding onto the gait belt with the resident in the wheelchair waiting for the therapist to return. It was only a few seconds and she did not attach the gait belt to the wheelchair. The investigation noted the COTA said when she went to get the resident for therapy, she saw the gait belt around the resident's abdomen and attached to the wheelchair. It wasn't tight to cause injury but secured to keep the resident in the chair. The facility's conclusion noted Resident #1 kept getting up and the sitter used the gait belt to keep the resident from getting up until therapy returned. On 4/10/2025 at 10:50 a.m., in an interview the Social Services Director said he has been at employed at the facility for about three years. He could not remember exactly what the resident said but he assisted in conducting interviews with other residents. He said all staff were educated on abuse Page 1 of 2 105439 105439 04/10/2025 Naples Health and Rehabilitation Center 2900 12th Street N Naples, FL 34103

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and neglect training. He said he has never seen a staff member restrain a resident and would report to a supervisor if he did. On 4/10/2025 at 11:15 a.m., in an interview Occupational Therapy Assistant Staff A said on 11/25/24 when she went into Resident #1's room for therapy she noticed the gait belt was wrapped around Resident #1 and the wheelchair. His caregiver was in the room next to him. She reported it to her Supervisor immediately. She said the resident was fine with no injuries. She said she removed the gait belt. She said the belt was around the residents waist to the back of wheelchair. She said she has never seen any other resident restrained and if she did she knew what to do. On 4/10/2025 at 11:20 a.m., in an interview Sitter Staff B said she has worked for the facility since 2001. She said she remembers Resident #1 and was working as a sitter for him on the day in question. She said Resident #1 was trying to jump out of bed and she put him in wheelchair and put gait belt around him but did not fasten it. She said she was just holding it to keep him from falling out of the wheelchair. She said the therapy lady said she was coming to get the patient and she forgot to remove the belt. She said she had never seen the gait belt in the room before that day. She said she was sent home while there was an investigation. She said she has since had training for abuse and neglect and not to use gait belt anymore. She now works only in dietary. She said she has never seen any resident restrained but if she did she would report it. 105439 Page 2 of 2