Failure to Conduct Ongoing Bedrail Assessments
Penalty
Summary
The facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet the needs of residents and to evaluate the risks associated with bedrail usage. Specifically, for one resident, the facility did not perform the required reassessments as per their policy. The policy stated that a nurse should complete reassessments at least quarterly, upon a significant change in status, or when there is a change in the type of bed, mattress, or rail. However, the last Side Rail/Grab Bar Review for the resident was completed several months prior, indicating a lapse in adherence to the policy. The resident involved had a care plan that required the use of bilateral enablers to assist with bed mobility, positioning, and transfers, with a nursing assessment to be completed quarterly, annually, and with any significant change in status. Despite this requirement, the facility did not conduct the necessary assessments, as confirmed by the Director of Nursing. This oversight was identified during an observation and subsequent interviews, highlighting the facility's failure to ensure the safety and appropriateness of bedrail usage for the resident.
Plan Of Correction
Side Rail/Grab Bar Review was completed on R56 retroactively. Like residents were assessed to ensure appropriate side rail/grab bar placement. Like residents assessed to ensure up to date assessments are completed. Education will be provided to the RNAC, Nurses and nursing management on side rail/grab bar review on or before 2/11/2025. Audits will be completed by the DON or designee weekly to ensure up to date assessments are completed x 4 weeks and monthly x 1 month. Audit results will be reviewed through the monthly QAPI process/meeting.