Failure to Obtain Physician Order and Care Plan for Bed Placement Against Wall
Penalty
Summary
The facility failed to obtain a physician order, develop a resident-centered care plan, and assess resident safety for the placement of beds against the wall for two residents. For one resident with dementia, repeated falls, and difficulty walking, the bed was observed pushed against the wall without documentation of a safety evaluation, physician order, or care plan addressing this arrangement. Similarly, another resident with high blood pressure, difficulty swallowing, and chronic pain was found with the bed against the wall, and stated that this placement was not requested. The clinical record for this resident also lacked evidence of a safety evaluation, physician order, or care plan for the bed placement. Facility policy prohibits the use of restraints for discipline or convenience and requires that restraints only be used as a last resort when medically necessary. The Director of Nursing confirmed that the required steps—physician order, individualized care plan, and safety assessment—were not completed for either resident regarding the bed placement against the wall.