Resident Restrained in Bed by Improper Use of Fall Mat
Penalty
Summary
A resident with diagnoses including aphasia, restlessness and agitation, dementia, lack of coordination, abnormalities of gait/mobility, and a need for assistance with personal care was found restrained in bed. The resident was observed by his daughter lying in bed with a thick mattress positioned upright along one side of the bed, held in place by a chair, while the other side of the bed was against the wall. The daughter reported this to nursing staff, who confirmed the presence of the fall mattress in an upright position. Interviews with LPNs revealed that fall mats are intended to be placed on the floor next to the bed to prevent injury, not upright along the bed, as this would restrict the resident's movement and effectively trap them in bed. The administrator and staff acknowledged that positioning the fall mat in this manner constituted a restraint, which is not permitted by facility policy except for medical treatment. The facility's restraint policy defines a physical restraint as any device that is attached or adjacent to the resident's body, cannot be easily removed by the individual, and restricts freedom of movement.