Mattress Used as Restraint Without Evaluation or Consent
Penalty
Summary
A deficiency occurred when a resident with metabolic encephalopathy and idiopathic normal pressure hydrocephalus had their mattress placed directly on the floor by an LPN without prior evaluation or consent. The LPN removed the resident's bed frame and placed the mattress on the floor without notifying other staff, the physician, or the resident's family. This action was witnessed by a CNA and later reported after the resident had been discharged. The facility's investigation substantiated the allegation of neglect, noting that the mattress on the floor acted as a restraint, as the resident was unable to get up unassisted, whereas previously the resident had been able to get out of bed independently. Facility policy required a device evaluation and consent from the resident or their representative before implementing any device that could act as a restraint. The policy also mandated physician notification and an order specifying the type, reason, and duration of use for any restraint. In this case, none of these steps were followed prior to the intervention, and the resident and their family were not informed of the risks and benefits associated with the change. The lack of a barrier between the mattress and the floor and the absence of required notifications and evaluations led to the substantiated finding of neglect.