Failure to Identify Bed Placement as Restraint Leads to Resident Fall
Penalty
Summary
The facility failed to recognize the placement of a resident's bed against the wall as a form of restraint and did not assess the resident's functional status to determine the necessity of this restraint. The facility's policy defines a restraint based on the resident's ability to remove a device, and in this case, the resident was unable to move the bed away from the wall independently. This oversight was identified during a review of the facility's policy, clinical records, observations, and staff interviews. The resident involved was admitted with diagnoses including hemiplegia and hemiparesis affecting the left non-dominant side, acute respiratory failure, and abnormal posture. Observations noted the resident's bed was positioned against the wall, which was intended to prevent the resident from irritating a wound. However, the resident was found on the floor between the bed and the wall after attempting to push the bed away with their legs, indicating the bed's placement restricted the resident's movement and contributed to a fall. This incident highlights the facility's failure to properly assess and document the use of restraints in accordance with the resident's medical needs.
Plan Of Correction
1. Resident R-5 bed was removed from the wall and is now centered in the room. 2. All residents' beds will be assessed to identify and possible restraints to ensure the functional status of the residents and to determine the use of a restraint. 3. Nurse Educator/Designee will re-educate the professional nursing staff on the policy, "Use of Restraints." 4. The DON/Designee will conduct weekly random audits times 2 months to ensure residents with beds against the wall are assessed properly for use of a restraint. 5. Audit results will be reviewed monthly by QAPI Committee.