Failure to Assess Bed Bolsters as Potential Restraints
Penalty
Summary
The facility failed to properly identify and assess the use of bed bolsters as potential physical restraints for two residents. According to facility policy, any device that restricts a resident's freedom of movement and cannot be easily removed by the resident should be evaluated as a possible restraint. For one resident with diagnoses including high blood pressure, Friedreich ataxia, and malnutrition, bolsters were observed on both sides of the bed, but there was no physician order for their use and no assessment or ongoing evaluation documented in the clinical record. The care plan noted a history of falls and included bolsters as an intervention, but did not address their use as a restraint. For another resident with high blood pressure, dementia, and arthritis, bolsters were also observed on both sides of the bed. While there was a physician order and care plan intervention for bolsters due to fall risk, the clinical record lacked any assessment or ongoing evaluation regarding their use as a restraint. During staff interviews, the DON confirmed that the facility did not identify bolsters as possible restraints and did not assess the residents' functional status to determine if the bolsters restricted their freedom of movement.