Improper Use of Physical Restraint with Upright Floor Mats
Penalty
Summary
A deficiency was identified when a resident with moderate cognitive impairment and multiple medical diagnoses, including metabolic encephalopathy and muscle weakness, was found in bed with floor mats propped upright against the bed and held in place by two wooden night tables. This arrangement prevented the resident from moving out of bed, effectively acting as a physical restraint. The resident required moderate assistance for bed mobility and was dependent for transfers and toileting, with no documented physician order for restraints or side rails in use. The facility's Restraint-Free Environment policy states that restraints are only to be used for the safety and well-being of residents and only after all alternatives have been tried unsuccessfully, and never for staff convenience or fall prevention. Despite this, a Certified Nurse Aide was responsible for placing the mats in this manner, believing it would prevent the resident from rolling out of bed and ensure safety. The incident was discovered during a federal survey, and interviews revealed that the mats were intentionally positioned upright and secured, rather than being placed flat on the floor as intended. Further investigation showed that the resident was bedridden, required a two-person assist for transfers, and had difficulty bearing weight. Staff interviews confirmed that the mats should not have been positioned upright, as this constituted a restraint. There was no evidence of physical harm to the resident, but the use of the mats in this way was not in accordance with facility policy or regulatory requirements, and there was no documented medical need or order for such a restraint.