Failure to Obtain Consent and Evaluation for Bed Placement as a Physical Restraint
Penalty
Summary
The facility failed to obtain a Safety Device Evaluation, consent, and/or a physician's order for the use of a physical restraint for one resident. Specifically, the resident's bed was positioned with the right side against the wall, which is considered a potential restraint. There was no documentation in the resident's electronic health record of an evaluation, consent, or physician's order related to this bed placement. The resident, who was moderately cognitively impaired according to the most recent assessment, stated that her bed had always been positioned this way and that no one had discussed the reason for it with her. Interviews with facility staff, including an LPN and the DON, confirmed that facility policy requires resident consent and an evaluation before implementing any type of restraint or safety device. Both staff members were unable to locate any documentation or consent for the bed placement for this resident. The facility's policy also requires that the care plan be updated and evaluated regularly for device use, but there was no evidence that these steps were followed in this case.