Failure to Obtain Order and Consent for Pommel Cushion Used as Restraint
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be free from physical restraints unless required to treat a medical symptom. A male resident with dementia, malnutrition, anxiety disorder, depression, hypertension, and dysphasia had a pommel cushion placed on his wheelchair. His Quarterly MDS showed use of a wheelchair, no documented use of physical restraints or alarms, and limited behavioral symptoms, including physical behavior toward others on 1–3 days and wandering on 1–3 days. The MDS did not identify the pommel cushion as a restraint, and there was no documentation in the record describing the medical symptoms being treated by the device. Record review showed no signed consent for the pommel cushion and no physician order in the electronic medical record. Nursing progress notes documented that after the pommel cushion was installed, the resident was no longer sliding to the edge of the chair, and that the IDT had met and, due to frequent unsafe attempts to get up and falls, applied a pommel seat to the wheelchair. During observation, the resident was seen seated in a wheelchair at the nurse’s station with a pommel cushion in place. The resident’s representative reported she was told by nursing staff that the pommel was used to keep him from falling out of the wheelchair and that she had not been called or asked to sign a consent before it was placed. Interviews with facility staff and the physician confirmed that the pommel cushion was implemented without prior physician notification, order, or consent. The DON stated the resident fell frequently and that the facility had tried other interventions before resorting to the pommel for safety, and initially did not consider it a restraint, so no consent was obtained, although she acknowledged an order should have been in the chart. The ADON stated she considered the pommel cushion a restraint and that policy required speaking to the physician and obtaining an order before use. The physician stated she was not aware the pommel cushion had been put in place until contacted by the DON, considered it a restraint, and stated the family should have been notified and consent obtained, including information on risks and benefits. The facility’s restraint policy defined physical restraints as devices that the resident cannot remove easily and that restrict freedom of movement, and required documentation of the medical symptoms warranting restraint use, which was not present in this case.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.