Failure to Assess and Maintain Bedrails for Residents
Penalty
Summary
The facility failed to appropriately assess and ensure the correct installation, use, and maintenance of bedrails for two residents. Resident R37, admitted with coordination issues, reduced mobility, and a need for assistance, was assessed as a fall risk and care planned to use bedrails. However, the resident expressed dissatisfaction with the bedrails, demonstrating that they were loosely attached. The Maintenance Director confirmed the bedrails were tightened after being found loose and stated that bedrails are only installed upon orders from the Director of Nursing or therapy. The Third Floor Unit Manager confirmed there were no physician orders or assessments for the bedrails. Resident R77, admitted with muscle weakness and difficulty walking, was also identified as a fall risk. The resident reported that the bedrails were loose and not useful, and there was no assessment for entrapment risk or physician orders for the bedrails. The resident did not request the bedrails, and the admission assessment indicated that the resident did not use them for bed mobility. The Director of Nursing was informed of these findings.
Plan Of Correction
1. R37 and R77 bedrails were tightened. They were also assessed for bedrails, physician order obtained, bed rails added to monitoring list. 2. All residents with side rails will be assessed for appropriateness and safety. If appropriate, order will be obtained from physician. Bed rails will be placed on and monitored. 3. Education to all department heads on process of adding and monitoring side rails. 4. Random audits by the Administrator/designee of 5 residents with side rails to ensure that resident has assessment, order and that side rails are tight and have been added to maintenance monitoring list once a week for one month, twice a week for one month, and once a month for one month. The findings of the audits will be brought to the Quality monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.