Failure to Obtain Physician Orders for Use of Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints not required to treat medical symptoms. A female resident with muscle weakness, lack of coordination, and severe cognitive impairment was observed in bed with bolster pads attached to all sides of her mattress, which prevented her from freely exiting the bed. Review of her care plan and physician orders revealed no documentation or orders for the use of these bolster pads as a restraint or safety device. The resident's care plan did not include the use of bolster pads as an intervention, and there were no physician orders authorizing their use. Interviews with the DON, ADON, and Administrator confirmed that the resident had arrived at the facility with the bolster pads, which had been provided by hospice, but staff were unaware of the need for physician orders for this equipment. The facility's policy defined physical restraints as any device that restricts freedom of movement and cannot be easily removed by the resident. The lack of physician orders and care plan documentation for the bolster pads constituted a failure to ensure the resident's environment was free from unauthorized restraints.