A resident with severe cognitive impairment, multiple comorbidities, and limited mobility was found with a pillow tucked under the bedsheet in a way that restricted movement, without any corresponding order or care plan indicating a medical need. A hospice nurse observed the pillow already in place and was unaware of who placed it or why. An LVN, the DON, and the Administrator each confirmed that this pillow placement constituted a restraint and was not an approved or trained practice, with the Administrator acknowledging it was used to keep the resident in bed. Facility policy prohibits restraints for discipline or convenience and specifically bans practices that restrict a bedbound resident’s ability to move, indicating the pillow’s use was inconsistent with established restraint policy.
A resident with COPD, Alzheimer’s disease, and anxiety disorder was not kept free from physical restraint when a CNA held both wrists during a brief change after the resident became combative. The resident had moderate cognitive impairment and rejection of care, and bruising was later documented on both forearms. Interviews showed staff continued the care while holding the resident’s wrists in the air, and the DON and ADON stated staff should stop and return later when a resident becomes combative.
A resident with dementia and multiple comorbidities had a pommel cushion placed on his wheelchair to address frequent falls and sliding, but the facility did not obtain a physician order, document the medical symptoms being treated, or secure consent from the resident’s representative. The MDS did not reflect use of a restraint, and there was no restraint consent in the record. The resident’s representative reported she was told by staff that the pommel was used to keep him from falling out of the wheelchair and that she had not been notified beforehand. The DON initially did not consider the pommel a restraint, while the ADON and the physician stated it was a restraint and that policy required prior physician involvement and informed consent, in contrast to the facility’s written restraint policy.
Two residents with severely impaired cognition were observed with position change alarms in use even though neither had a physician order for the alarm. One resident’s care plan noted the alarm had been discontinued because the resident could manipulate it, while the other resident’s care plan addressed falls related to confusion but did not include the alarm. The DON and ADM both confirmed the alarms should have had orders, and the ADM stated the facility did not have a system to monitor position change alarms.
A resident with dementia, severe functional dependence, and a history of falling from bed had a scoop mattress ordered and observed in use for fall prevention, but the medical record lacked consent for the device. The ADON stated she did not think about obtaining consent, and the ADM acknowledged the scoop mattress could be a restraint and that staff were responsible for obtaining consent before applying it.
Surveyors found that two residents were subjected to physical restraints in the form of pillows tucked under their bed sheets, restricting their movement and not required for medical treatment. Staff interviews and record reviews confirmed that these interventions were not care planned or medically necessary, and facility policies prohibit such practices unless indicated for medical reasons.
A resident with cognitive impairment, muscle weakness, and seizures was found with a bolster mattress on the bed without a physician order or care plan intervention for its use. Staff, including an LVN and the Interim DON, were unaware of the need for a physician order, and facility policy required such orders for physical restraints.
A resident with severe cognitive impairment and muscle weakness was found using a bolster mattress on her bed without a physician order or assessment. The care plan identified the resident as a fall risk, but staff confirmed that no order was in place for the equipment, contrary to facility policy requiring physician involvement for restraint use.
Two residents were found using bolster mattresses as physical restraints without required physician orders or proper care plan documentation. Staff confirmed that physician orders were necessary for these devices, but none were present in the records, contrary to facility policy.
A resident with spastic quadriplegic cerebral palsy was observed using a chest harness in a wheelchair without a physician order, consent, or documented evaluation, despite being unable to remove the device independently. Staff considered the harness a positioning device, but facility policy defined it as a restraint due to the resident's inability to remove it, and required a physician order and consent, which were not present.
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