Use of Bed Placement as Physical Restraint Without Proper Authorization
Penalty
Summary
Two residents were found to have their beds positioned against the wall, with the opposite side rails raised, effectively restricting their freedom of movement. Both residents had significant medical histories, including cerebral infarction, major depressive disorder, psychosis, and epilepsy. Assessments indicated that one resident had moderately intact cognition and required maximal assistance with transfers, while the other had intact cognition but was dependent on staff for dressing, toileting, and bathing. Observations confirmed that the beds were placed against the wall, and this setup was verified by staff during interviews. Staff, including two LVNs and the Director of Nursing, acknowledged that placing a bed against the wall is considered a form of physical restraint, which restricts resident movement and could potentially cause injury. Facility policy requires that restraints only be used for medical symptoms and after other alternatives have been tried unsuccessfully, with a physician's order. In these cases, there was no indication that such orders or alternative measures were in place, leading to the deficiency.