Failure to Assess and Care Plan Use of Body Pillows and Concave Mattress as Restraints
Penalty
Summary
The facility failed to identify and assess the use of full body pillows and a concave mattress as physical restraints for a resident with cognitive impairment and a high risk for falls. Observations showed that the resident was consistently positioned in bed with full-length body pillows placed along both sides of the body, under a fitted sheet, on top of a concave mattress. Staff interviews confirmed that these interventions were used specifically to prevent the resident from getting out of bed, yet there was no documentation of a restraint assessment or inclusion of these interventions in the resident's care plan. The resident's medical record indicated a history of falls, cognitive impairment, and unsteady gait. Progress notes and post-fall documentation revealed multiple incidents where the resident exited the bed and ambulated unsupervised, despite the presence of body pillows and a concave mattress. On several occasions, the resident was found on the floor after attempting to self-transfer, and ultimately sustained a left pelvic fracture following a fall when the body pillows were in place. There was no evidence in the medical record of an assessment or reassessment for the use of these devices, even after falls occurred. Staff, including CNAs, an LPN, and the DON, acknowledged that the body pillows were intended to restrict the resident's ability to get out of bed and that no formal assessment or care plan intervention had been completed for their use. The facility's own restraint policy required an assessment prior to the use of any restraint and regular reassessment, but this was not followed. The hospice nurse practitioner also noted that the combination of body pillows and a concave mattress increased the resident's risk for injury by creating additional obstacles to safe bed exit.