Unnecessary Physical Restraint Due to Bed and Bedside Table Placement
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and total dependence for activities of daily living was subjected to unnecessary physical restraint. The resident's bed frame was observed to be set very low with a sagging mattress, which restricted the resident's ability to get out of bed. Additionally, a bedside table was positioned alongside the bed, blocking the resident's movement. These conditions were observed on two separate occasions, and staff interviews confirmed that the setup was intended to prevent the resident from getting up due to a high risk of falls. The facility's own policy states that restraints should only be used for medical symptoms and not for staff convenience or fall prevention, and that equipment should not be used to restrict resident mobility. Both the LVN and DON acknowledged that the bed and bedside table placement restricted the resident's movement and could cause entrapment. The care plan for the resident included a goal to prevent signs and symptoms of entrapment, but the observed practices were inconsistent with this goal and the facility's restraint policy.