Failure to Conduct Ongoing Bedrail Assessments
Penalty
Summary
The facility failed to comply with regulations regarding the use of bedrails for three residents. For Resident R47, the facility did not conduct ongoing accurate assessments to ensure the bedrails met the resident's needs and did not reassess the risks associated with bedrail usage since May 2024, despite having a physician order for bilateral assistive handrails. Similarly, Resident R65 had not been reassessed for bedrail usage since September 2024, even though a physician order was in place for bilateral assistive handrails. Observations confirmed the presence of enabler bars on both residents' beds without recent assessments. Resident R253 was admitted to the facility without a physician order for enabler bar usage, yet observations revealed the presence of enabler bars on the resident's bed. The facility's Regional Director of Clinical Services acknowledged that the bedrails were not captured in the admission assessment for Resident R253, and they were subsequently removed. The facility's failure to obtain a physician order and conduct ongoing assessments for bedrail usage was confirmed by the Regional Director of Clinical Services.
Plan Of Correction
R 65 and 47 had a bed rail assessment completed, order obtained, and care plan updated. R 253 had a bed rail assessment and bed rails were discontinued. To identify other residents that have the potential to be affected, the Director of Nursing (DON)/designee reviewed current residents with bedrails to ensure a physician order is obtained and ongoing accurate assessments are completed. Negative findings will be addressed. To prevent this from recurring, the Regional Director of Clinical Services (RDCS)/designee educated staff on the bedrail policy. To monitor and maintain ongoing compliance, the DON/designee will audit bedrails for need, order and care plan weekly x4 then monthly x 2. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.