Incomplete Medical Record and Missing Physician Order for Bolster Pillow
Penalty
Summary
The facility failed to ensure that the medical record for one resident was accurate and complete regarding the use of bilateral bolster pillows. The resident, who was unable to make medical decisions, had a care plan intervention for bilateral bolster pillows following an unwitnessed fall from bed. However, the medical record review revealed that the informed consent form for the bolster pillow was not signed by the provider who obtained the consent, and there was no physician's order for the use of the bolster pillow documented in the resident's records. During interviews and concurrent medical record reviews, both an LVN and the DON confirmed that a bolster pillow required both a signed consent from the resident or representative and a physician's order, neither of which were present in this case. The facility's policy on informed consent also specified that the healthcare professional proposing the intervention is responsible for providing information and obtaining proper consent, which was not followed in this instance.