Failure to Provide Assistive Device for Bed Mobility
Penalty
Summary
The facility failed to provide an assistive device for a resident, identified as Resident R23, to maintain independence with bed mobility. The facility's policy for bed safety requires an assessment for safety, medical conditions, comfort, and freedom of movement, with input from the resident and consultation with a physician. Despite a physician's order dated May 21, 2024, for 1/4 side rails as an enabler for bed mobility, the facility did not implement this order. The resident, who is alert, oriented, and independent with all activities of daily living, expressed the need for bed rails to assist with frequent nighttime bathroom visits. The deficiency was further highlighted by the inaccurate completion of the side rail evaluation, which marked the resident as not assessed for potential bed rail use. A regional registered nurse confirmed that the facility does not use side rails and that the assessment indicated the resident did not need them, contradicting the physician's order. This oversight resulted in the resident not receiving the necessary support to maintain independence in bed mobility, as initially planned upon admission to the facility.
Plan Of Correction
1. Resident R23 had a side rail installed. 2. Full house side rail assessment has been done. 3. Staff will be educated on the components of this regulation with an emphasis on increasing or preventing the decrease in residents' range of motion and mobility. 4. 5 residents will be audited to ensure they have a side rail if needed 1x week for 1 month, 2x a month for one month and then 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.