Failure to Obtain Physician Order for Bolster Mattress Used 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 a history of lack of coordination, muscle weakness, and seizures was observed with a bolster mattress on the bed. Review of the resident's care plan and physician orders revealed that there was no physician order for the use of the bolster mattress, and the care plan did not include this intervention. The resident required total assistance with activities of daily living and was at risk for falls and seizures, but the use of the bolster mattress was not documented as an intervention in the care plan. During interviews, staff members, including an LVN and the Interim DON, were unsure whether a physician order was required for the bolster mattress and confirmed that no such order was present. The facility's policy indicated that physical restraints should only be used when warranted by medical symptoms and with appropriate orders. The lack of a physician order for the bolster mattress constituted a failure to ensure the resident's environment was free from unnecessary physical restraints.