Failure to Obtain Physician Order for Bolster Mattress Used as 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 bolster mattress was placed on the resident's bed as an intervention for fall risk, but there was no physician order authorizing its use. The resident's care plan included the bolster mattress for safety, and the Director of Nursing acknowledged that the equipment was provided due to the resident's fall risk and that it was her responsibility to obtain a physician order, which she failed to do. Record review showed that the resident had diagnoses including unsteadiness on feet and repeated falls, required extensive assistance with activities of daily living, and was unable to complete a BIMS interview. Observations confirmed the presence of the bolster mattress, and interviews with facility staff confirmed that the required physician order was missing. Facility policy requires physician notification and adherence to state regulations when restraints are used, but this process was not followed in this case.