Failure to Obtain Orders and Consent for Use of Restraint Devices
Penalty
Summary
Surveyors identified that multiple residents were subjected to the use of beds with bolsters or concave mattresses, which functioned as physical restraints, without the required physician's order, informed consent, or restraint assessment. Observations revealed that residents were found lying in beds with bolsters around the edges of the mattress, and staff confirmed that these devices were used to prevent falls but also acknowledged that they could restrict residents' ability to get out of bed freely. Staff interviews further confirmed that the use of these devices could be considered a restraint and that appropriate assessments, orders, and consents were not obtained prior to their use. The records for several residents, including those with chronic pain syndrome, history of falls, muscle wasting, dementia, quadriplegia, and impaired cognition, showed no documentation of a physician's order, informed consent, or restraint assessment for the use of the bolstered or concave mattresses. Care plans and fall risk evaluations indicated that these residents were at high risk for falls, but interventions documented did not include the use of these restraint devices, nor were they incorporated into the residents' comprehensive care plans. Staff and the DON acknowledged during interviews that the required processes for restraint use, including assessment, order, consent, and care planning, were not followed. Facility policies and procedures reviewed by surveyors clearly stated that physical restraints require a physician's order, informed consent, and an interdisciplinary team assessment, and that these steps must be documented in the resident's medical record. Manufacturer guidelines for the mattress products also emphasized the need to follow facility policies for assessment and monitoring. Despite these requirements, the facility failed to ensure compliance, resulting in the use of restraint devices without proper authorization or documentation for several residents.