Failure to Assess, Obtain Order, and Document Use of Pommel Cushion
Penalty
Summary
A deficiency occurred when a resident was observed seated in a reclining wheelchair with a pommel cushion and non-slip fabric, without prior assessment of the need for this device. The Certified Nursing Assistant (CNA) stated that the cushion was used to prevent the resident from sliding forward and falling out of the chair. The Director of Nursing (DON) was unaware of the cushion's use and confirmed that it was not included in the resident's care plan. The restorative aide reportedly added the cushion due to the resident's seizure disorder and tendency to scoot down in the chair, and the hospice nurse was aware of its use. However, there was no documentation of a physician's order for the cushion, nor was its use reflected in the care plan. The resident in question had multiple diagnoses, including epilepsy, pseudobulbar affect, delusional disorder, abnormal breathing, sleep apnea, hypothyroidism, Down syndrome, pain disorder, and depression. The care plan noted the resident's risk for falls and her behavior of sliding or scooting forward in her wheelchair, but did not include any interventions related to the pommel cushion. The facility's policy defined physical restraints and required that their use be preceded by less restrictive alternatives, informed consent, and a physician's order, none of which were documented in this case.