Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to ensure proper assessment and documentation for the use of side rails for a resident. Observations revealed that the resident's bed had two metal side rails on the right side and one on the left, despite the admission assessment indicating that side rails were not needed. There were no physician orders or further assessments documented to justify the use of side rails for this resident. Interviews with facility staff, including the ADON, Rehab Director, and an LPN, revealed confusion and inconsistency regarding who is responsible for conducting bed rail assessments. The ADON stated that 'Rehab' is responsible, while the Rehab Director indicated that 'Nursing' handles the assessments. The LPN mentioned that both Nursing and Rehab conduct the assessments, but acknowledged the lack of an order for bed rails and the admission assessment's indication that side rails were unnecessary.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.7.25 resident #302 was assessed by licensed nurse for use of bed rails and consent was obtained for use; no concerns identified. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: A facility quality review was completed on 4.22.25 by Director of Nursing on current residents for use of bed rails to ensure appropriate physician order in place for mobility to reflect current status. Any issues identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On 4.22.25 Director of Nursing completed education with current nursing staff and staff on the components of F700 bed rails with emphasis on ensuring assessment in place and reflective of resident current status for use of bed rails for mobility by the Director of Nursing/designee. Newly hired nursing staff and staff will be educated on the components of F700 bed rails with emphasis on ensuring assessment in place and reflective of resident current status for use of bed rails for mobility by the Assistant Director of Nursing/Designee during orientation as part of the systematic change. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct audits of 5 residents twice a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure compliance with F700 with emphasis on ensuring assessment in place and reflective of resident current status for use of bed rails for mobility. The findings of these quality monitorings to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee.