Failure to Implement Alternative Interventions Before Siderail Installation
Summary
The facility failed to implement appropriate alternative interventions before installing bilateral 1/4 siderails for a resident, which could lead to the risk of entrapment and physical injury. The resident, who was admitted and readmitted with conditions such as hypertensive heart disease, chronic kidney disease, heart failure, and muscle weakness, was found to have moderately impaired cognition and was dependent on assistance for mobility. Despite these conditions, the facility did not attempt alternative interventions before resorting to siderails. The resident's medical records indicated that the siderails were installed for bed mobility and to assist with getting in and out of bed. However, the facility's assessment and care plan did not reflect the use of alternative methods before the installation of siderails. The assessment noted the use of frequent monitoring, reminders to use call lights, and restorative care, but no additional alternative interventions were implemented. Furthermore, the resident's head, neck, and chest were not measured to assess the risk of entrapment. Interviews with the Director of Nursing (DON) revealed that the facility did not follow its policies and procedures for bedside rail assessment and management. The DON acknowledged that the immediate use of siderails without implementing appropriate interventions could cause entrapment. The facility's policy required the use of alternate methods and the least restrictive measures before installing siderails, which was not adhered to in this case.
Penalty
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Staff did not assess or attempt alternatives before using bedrails for a resident with multiple medical conditions and intact cognition. The resident was observed with bedrails in use and could not recall being informed of their risks or benefits, and the clinical record lacked documentation of alternatives or a bedrail assessment.
Staff did not offer or attempt alternatives to bed rails or assess for entrapment risk before using bed rails for four residents. Clinical records lacked required documentation, and interviews with an LPN indicated a lack of awareness and policy regarding entrapment risk assessment.
The facility staff failed to implement bed rail requirements for four residents, lacking evidence of consent, alternatives attempted, and review of risks and benefits before installation. Observations confirmed the use of bed rails without proper documentation or physician's orders. Interviews with staff revealed a lack of awareness and documentation of necessary assessments and consents.
Facility staff failed to accurately assess and document bed rail use for two residents, leading to deficiencies in safety evaluations. Misunderstandings among staff about what constitutes a side rail contributed to the inaccurate documentation. The director of nursing confirmed the errors, acknowledging that the assessments did not align with the facility's policies.
A resident in a persistent vegetative state was provided with bed rails without attempting alternatives or assessing entrapment risks. The facility's documentation inaccurately indicated the resident could use the rails as an enabler, despite being non-verbal and fully dependent on staff. The facility also failed to provide necessary documentation for the installation and safety of the bed rails, contributing to the deficiency.
A resident was observed with raised bed rails without a documented safety assessment. The facility failed to conduct necessary evaluations by PT and OT to determine the resident's need and ability to use side rails safely. The Director of Nursing confirmed the absence of such assessments in the resident's clinical records.
Failure to Assess and Attempt Alternatives Prior to Bedrail Use
Penalty
Summary
Facility staff failed to assess and attempt alternatives prior to the use of bedrails for one resident. The resident, who had a history of right above the knee amputation, atherosclerosis, diabetes, and chronic kidney disease, was cognitively intact and required varying levels of assistance with self-care activities. Despite these needs, there was no documentation in the clinical record of any alternatives being tried before bedrails were implemented, nor was there evidence of a bedrail assessment. Observations showed the resident with bilateral bedrails in use on multiple occasions, both while in bed and seated at the bedside. During an interview, the resident expressed a preference for bedrails but could not recall requesting them or being informed of their risks and benefits. The record review confirmed the absence of documentation regarding alternatives, their effectiveness, or informed consent. Facility leadership did not provide comments or concerns when interviewed about these findings.
Failure to Assess and Document Alternatives Prior to Bed Rail Use
Penalty
Summary
Facility staff failed to implement required procedures regarding the use of bed rails for four residents. In each case, staff did not offer or attempt appropriate alternatives to bed rails before their use, nor did they assess the residents for risk of entrapment. Observations confirmed that the residents were using bilateral or quarter bed rails in the upright position, but clinical records lacked documentation of any alternatives being considered or attempted, as well as any assessment for entrapment risk. Interviews with an LPN revealed that alternatives such as a single bed rail, grab bar, or wedges should be considered and documented prior to bed rail use, but this was not done. The LPN also stated there was no awareness of an assessment tool for entrapment risk in the facility. When the administrator and DON were informed of these concerns, the facility was unable to provide a specific policy addressing the offering or attempting of alternatives or the assessment for entrapment risk prior to bed rail use.
Failure to Implement Bed Rail Requirements
Penalty
Summary
The facility staff failed to adhere to bed rail requirements for four residents, resulting in deficiencies in the assessment and consent process. For Resident #48, the staff did not attempt alternatives before using bed rails, failed to assess the resident for risk of entrapment, did not review the risks and benefits with the resident or their representative, and did not obtain informed consent. The resident's clinical record lacked documentation regarding bed rails, and there was no physician's order for their use. Observations confirmed the presence of bed rails, and interviews with staff revealed a lack of awareness and documentation of the necessary assessments and consents. Similarly, for Resident #166, the facility staff did not provide evidence of consent for bed rail use, did not attempt alternatives, and did not review the risks and benefits before installation. The resident was cognitively intact and used the bed rails for mobility, but there was no physician's order or comprehensive care plan documenting their use. The admission assessment and bed safety evaluation failed to include necessary information about alternatives, risks, benefits, and consent. For Resident #187, who was severely impaired in decision-making, and Resident #221, who was cognitively intact, the facility staff again failed to provide evidence of consent, alternatives attempted, and a review of risks and benefits before bed rail installation. Observations confirmed the use of bed rails, but there were no physician's orders or comprehensive care plans documenting their use. Interviews with staff indicated a lack of clarity and documentation regarding the assessment and consent process for bed rail use.
Inaccurate Bed Rail Assessments for Two Residents
Penalty
Summary
The facility staff failed to complete accurate bed rail assessments for two residents, leading to deficiencies in documentation and safety evaluations. For one resident, the assessment tool inaccurately documented the presence of grab bars on both sides of the bed, marking 'no' to the use of devices that could be considered restraints. Interviews with staff revealed a misunderstanding of what constitutes a side rail, as the LPN believed grab bars or halo bars were not considered side rails. The director of nursing was not familiar with the specific resident but acknowledged that beds typically have rails unless removed. The facility's policy requires evaluation of entrapment zones whenever bed rails or similar devices are used, but this was not properly documented or assessed. Similarly, for another resident, the assessment tool failed to accurately document the presence of halo bars attached to both sides of the bed, again marking 'no' to the use of restraint devices. The LPN reiterated the same misunderstanding regarding what constitutes a side rail. The director of nursing confirmed the assessment was incorrect, as the resident did have halo bars, which were removed on the day of the interview. These findings were communicated to the interim administrator and the director of nursing, highlighting a lapse in the facility's adherence to its own policies and procedures regarding bed rail assessments.
Failure to Assess Alternatives and Risks Before Bed Rail Use
Penalty
Summary
The facility staff failed to attempt alternatives before implementing the use of bed rails for a resident in a persistent vegetative state, identified as Resident #49 (R49). The staff applied bed rails without assessing the risk of entrapment, which is a necessary step before their use. The resident had a history of a fall, and the facility did not explore other options or conduct a thorough risk assessment before deciding on bed rails. The resident's care plan did not indicate that the resident could assist with daily activities, and the bed rails were not used as an enabler, contrary to what was documented. The clinical record review revealed that R49 had multiple diagnoses, including persistent vegetative state and cerebral palsy, and was non-verbal and unable to respond to stimuli. Despite this, the facility's documentation inaccurately indicated that the resident could use the bed rails as an enabler. Interviews with staff, including a certified nursing assistant and the regional director of clinical services, confirmed that R49 was entirely dependent on staff for care and could not use the bed rails independently. The facility's maintenance director also failed to provide documentation of the installation of the bed rails or the manufacturer's user manual, which are necessary for ensuring proper installation and safety. The facility's policy required maintenance and nursing to collaborate on bed system audits to ensure compatibility and safety, but this was not adequately followed. The facility was unable to provide evidence of a maintenance work order or the manufacturer's specifications for the bed rails, indicating a lack of proper documentation and adherence to safety protocols. These oversights contributed to the deficiency identified during the survey, as the facility did not ensure the safe and appropriate use of bed rails for R49.
Failure to Assess Resident for Safe Use of Bed Rails
Penalty
Summary
The facility staff failed to perform a safety assessment for the use of side rails for Resident #93. On August 27, 2024, the resident was observed sitting up in bed with both quarter side rails raised while eating breakfast. A review of the resident's clinical record, including assessments, physician orders, and care plan, showed no evidence of an assessment for the need or safe use of side rails. On August 28, 2024, the Director of Nursing confirmed the absence of a safety assessment for the resident's use of side rails. Further interviews revealed that before a resident's bed is equipped with side rails, assessments by physical therapy and occupational therapy are required to determine the resident's ability to use the side rails safely and the necessity of the side rails. However, these assessments were not completed for Resident #93, and no orders were entered into the system by PT or OT.
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