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F0558
D

Failure to Provide Necessary Bed Rails for Resident

Lancaster, Pennsylvania Survey Completed on 01-27-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide reasonable accommodation for a resident's needs, as evidenced by the lack of bed rails that were necessary for the resident's positioning and mobility. The resident, who was admitted with acute respiratory failure, chronic obstructive pulmonary disease, anxiety disorder, muscle wasting, and difficulty walking, had a documented need for bed rails to assist with positioning and rising from a lying to a sitting position. Despite a request from the resident's power of attorney for care and a completed Bed Side Rail Evaluation indicating the need for bed rails, the facility did not install them until January 10, 2025. The Director of Nursing was unaware of the incomplete evaluation from November 11, 2024, which resulted in the resident not receiving the necessary bed rails until two months later. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the resident should have had bed rails installed as per the evaluation conducted in November 2024. This deficiency highlights a failure in accommodating the resident's needs in a timely manner, as required by the regulations.

Plan Of Correction

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. 1. Resident Ginny Godfrey currently has enabler bars on bed. 2. Residents with side rails/enablers were reviewed for order. Bed side rail evaluation is complete and that side rail/enablers are appropriate. 3. Licensed nursing staff were re-educated on completion of Bed side rail evaluation and completing work order to ensure that side rail/enablers are placed on the bed. 4. DON or designee will complete random audits of Bed side rail evaluation, will be completed weekly X4, then monthly x2 on completed assessments to ensure that if side rails/enablers are appropriate they are placed on the bed. 5. Date of compliance: 2/25/25.

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