Improper Use of Positioning Device as Restraint
Penalty
Summary
A deficiency was identified when a resident with a history of cerebral infarction resulting in left-sided hemiplegia and hemiparesis, severe cognitive dysfunction (BIMS score 0/15), and full dependence on staff for activities of daily living was found to be restrained in bed. The resident was admitted to hospice care and required a wheelchair for mobility with staff assistance. The care plan indicated the use of pillows for injury prevention due to involuntary movements, but did not specify the use of restraints. Multiple observations revealed a full-length body pillow tucked under the fitted sheet on the resident's left side, positioned in a way that restricted the resident from getting out of bed. Staff interviews confirmed the pillow was consistently used to prevent the resident from falling out of bed and to keep the resident from getting up. The Director of Nursing acknowledged that the placement of the pillow under the fitted sheet and out of the resident's reach could be considered a restraint. The MDS assessment did not indicate the use of restraints for this resident.