Failure to Conduct Timely Assessments and Maintenance for Enabler Bars
Penalty
Summary
The facility failed to complete necessary assessments and maintenance checks for enabler bars for four residents, leading to a deficiency in care. Resident #2 was observed with bilateral enabler bars affixed to her bed, but her care plan did not include any information related to these bars. The maintenance logs for Resident #2 were incomplete, with no record of the initial four-day monitoring after installation. The Maintenance Director confirmed that the resident needed the enabler bars, but there was no documentation to support this need. Resident #71 had a care plan for assist rails to enhance mobility, but the quarterly assessments for the continued use of enabler bars were not completed on time. The last assessment was five months late. The maintenance logs were unclear, with an 'X' next to the room number, making it uncertain whether the enabler bars were inspected for safety and functionality. Similarly, Resident #76's assessments were not completed at the appropriate intervals, and the maintenance logs showed lines through the initial monitoring days, indicating a lack of clarity in the documentation. Resident #75 had an initial assessment for enabler bars, but no subsequent assessments were completed. The facility's policy required quarterly evaluations of residents' need for rails, which was not adhered to. The Clinical Care Coordinator acknowledged the responsibility of unit managers to ensure assessments were completed, but the last monthly audits of enabler bars were conducted months prior, indicating a systemic issue in maintaining compliance with the facility's policies.