Unapproved Use of Physical Restraint for Fall Prevention
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including schizoaffective disorder, intellectual disabilities, a wedge compression fracture, and a history of falls, was found to have a blue wedge cushion placed between the mattress and bed frame on one side of the bed, while the other side of the bed was against the wall. The wedge cushion was used to prevent the resident from falling out of bed, as confirmed by interviews with nursing staff. The resident's care plan addressed fall risk and included interventions such as ensuring a safe environment and keeping the call light within reach, but did not mention the use of a wedge cushion. There was also no physician order or care plan documentation for the wedge cushion. Observations over two days confirmed the continued use of the wedge cushion in this manner. Staff interviews revealed the wedge was intended to keep the resident from falling or climbing out of bed, and the DON acknowledged that this setup could restrict the resident's movement. Facility policy states that residents have the right to be free from physical restraints not required for medical treatment, and the facility had identified no residents as having a physical restraint. The use of the wedge cushion in this way constituted a physical restraint that was not care planned or ordered.