Failure to Obtain Physician Order for Use of Bolster Mattress as Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints not required to treat medical symptoms. Specifically, a resident with severe cognitive impairment, muscle weakness, and a history of unsteadiness was observed lying on a bolster mattress on her bed. The resident's care plan identified her as a fall risk and included interventions such as a fall mat and keeping the bed in a low position, but there was no physician order or assessment for the use of the bolster mattress. Record review confirmed the absence of a physician order for the bolster mattress, and interviews with facility staff, including the ADON and Administrator, acknowledged that an order should have been obtained for the equipment. The facility's policy requires that restraints only be used when warranted by medical symptoms and with appropriate physician involvement, which was not followed in this instance.