Failure to Obtain Physician Orders for Bolster Mattresses Used as Physical Restraints
Penalty
Summary
The facility failed to ensure that two residents were free from the use of physical restraints not required to treat medical symptoms, specifically regarding the use of bolster mattresses. For one resident with muscle weakness and unsteadiness, the care plan identified her as a fall risk and included the use of a bolster mattress as an intervention. However, there was no physician order for the device, and the resident was observed lying on the bolster mattress. Facility staff confirmed that a physician order was required but not present in the records. Similarly, another resident with repeated falls and muscle weakness was observed using a bolster mattress, but there was no care plan or physician order for the device. Staff interviews confirmed the absence of required physician orders for both residents. The facility's policy required an interdisciplinary assessment and physician orders for such devices, but these steps were not followed, resulting in the deficiency.