Failure to Prevent Use of Physical Restraints Not Medically Indicated
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from physical restraints not required to treat medical symptoms, specifically for two residents. Both residents were found with pillows tucked under their bed sheets, which restricted their movement and ability to get out of bed. These interventions were not documented in their care plans as medically necessary, nor were they listed as required devices for fall prevention or other medical needs. Staff interviews confirmed that the use of pillows in this manner was not part of the residents' care plans and was not medically indicated. One resident, a female with severe cognitive impairment, multiple neurological and psychiatric diagnoses, and a history of falls, was observed lying in bed with a long body pillow tucked under her bed sheet. Staff, including CNAs and nurses, acknowledged that the pillow was used to prevent the resident from falling out of bed due to her constant movement, but also confirmed that this practice was not permitted and was considered a restraint. The resident's care plan included fall precautions such as low beds and floor mats, but did not mention the use of pillows as a restraint or intervention. A second resident, a male with severe cognitive impairment, muscle weakness, and a history of stroke, was also found with a pillow propped under his bed sheet. This resident was dependent on staff for all activities of daily living and was unaware of the presence of the pillow. Staff interviews and review of facility policies confirmed that the use of such devices was not allowed unless medically necessary and care planned. Facility policies and staff training materials reviewed by surveyors emphasized the prohibition of restraints for discipline or convenience, and staff were trained not to use pillows or similar devices in this manner.