Failure to Obtain Physician Orders for Scoop Mattresses Used as Restraints
Penalty
Summary
The facility failed to ensure that three residents were free from the use of physical restraints, specifically scoop mattresses, which were implemented without physician orders. Observations confirmed that these residents, all of whom had significant cognitive impairments and required substantial or extensive assistance with activities of daily living, were using scoop mattresses. Record reviews for each resident showed no corresponding physician orders authorizing the use of these mattresses. Interviews with the ADON and DON confirmed that the scoop mattresses were in use for residents identified as fall risks, but neither staff member could locate physician orders for these devices. The facility's own policy requires that physical restraints not be used for discipline or convenience and mandates physician orders to ensure that such devices are not being used as restraints. The absence of physician orders for the scoop mattresses constituted a failure to comply with this policy.