Resident Restrained in Bed Using Mattress and Chair Without Proper Authorization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from unnecessary physical restraints. The resident had diagnoses including cirrhosis with ascites, diabetes mellitus, COPD, and depression, with an MDS showing intact cognition, partial assistance with ADLs, supervision with transfers, and independence with bed mobility. The resident’s care plan addressed a need for restful sleep and identified fall risk, with interventions such as keeping the room quiet, dimming lights, offering a back rub or snack, and using a fall mattress on the floor next to the bed or a perimeter-defining mattress. On the night in question, nursing documentation indicated the resident became agitated, restless, combative, attempted to toss herself to the floor, and was yelling for her son. A hospice nurse assessed the resident and obtained an order for Ativan every four hours, after which the resident became calm. Later during the night shift, a CNA reported that the resident was restless, grabbing at the air, not responding to direction, and attempting to throw herself out of a chair. At approximately 5:45 a.m., this CNA transferred the resident to bed, covered her with a bedsheet, and placed a mattress upright against the open side of the bed, secured in place with the resident’s locked chair, while the other side of the bed was against the wall. Day-shift CNAs arriving later that morning observed the resident asleep in bed with a mattress pressed against one side of the bed, held in place by a locked chair, and the opposite side of the bed against the wall. One CNA reported that a sheet and blanket were tucked under the mattress over the resident, along with pillows positioned in a way that prevented the resident from exiting the bed, making it impossible for her to get out. Another CNA confirmed seeing the mattress and locked positioning chair against the bed. The DON confirmed that the facility verified the CNA had restrained the resident in bed by placing the mattress against the bed in this manner, resulting in the resident being unable to exit the bed, contrary to the facility’s policy that residents have the right to be free from physical restraints and that any ordered restraint must be the least restrictive and used for the least amount of time with ongoing reevaluation.
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