Failure to Properly Assess and Document Use of Parameter Mattress as Restraint
Penalty
Summary
The facility failed to ensure that a parameter mattress, which is a type of mattress cover designed to create a gentle barrier around the edge of the bed, was not used in a manner that restrained a resident while in bed. The resident in question had moderate cognitive impairment, required assistance with all activities of daily living, and had multiple diagnoses including dementia, anxiety, and limited mobility. The resident's care plan indicated the use of a lipped mattress to decrease fall risk, but did not document the use of the parameter mattress as a restraint. The Minimum Data Set (MDS) and physical device assessment did not indicate the use of restraints or the parameter mattress for this resident. During observations and interviews, staff confirmed that the resident had a parameter mattress in place for several years to prevent falls, despite the resident being non-ambulatory and unable to get out of bed independently for approximately a year. The parameter mattress was not assessed or documented in the physical device assessment as required, and staff were unsure why it remained in use. The facility's policy defined physical restraints as any device that restricts freedom of movement and specified that such restraints should only be used for medical symptoms and not for staff convenience or fall prevention. The use of the parameter mattress in this case was not supported by assessment or documentation, leading to the deficiency.