Improper Use of Bed Placement as a Physical Restraint
Penalty
Summary
The facility failed to ensure a resident was free from the use of physical restraints when the resident’s bed was positioned directly against a wall in a way that restricted voluntary movement. The resident had been admitted with diagnoses including cerebral infarction, an unstageable pressure ulcer on the right upper back, and a gastrostomy tube, and had severely impaired cognitive skills for daily decision-making per the MDS. During observation with an LVN, the resident’s bed was noted to be placed so that there was no space on the left side between the bed and the wall, preventing the resident or staff from accessing that side. The LVN stated she was unsure whether there was a physician order for this bed placement and confirmed that the medical record contained no such order. Further review with the LVN showed that the resident’s care plan did not include any interventions addressing the bed being placed against the wall. In interviews, the LVN, an RN, and the DON each acknowledged that a bed positioned against the wall, or less than one foot from the wall, was considered a form of restraint that could limit the resident’s movement. The DON stated that the resident’s bed placement against the wall was considered a restraint and that the facility failed to ensure the bed was not placed in this manner. Review of the facility’s restraint policy indicated that restraints require a physician order, are to be used only when necessary as determined by the IDT, and must be in accordance with the resident’s assessment and plan of care, conditions that were not met in this case.
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