Failure to Follow Care Plan for Side Rail Use
Penalty
Summary
A deficiency was identified when staff failed to implement a patient's care plan as ordered. The patient, who was legally blind, dependent on staff for activities of daily living, and at high risk for falls, had a care plan and physician order specifying that one fourth side rails should be up while in bed to assist with positioning and turning. During an observation, the patient was found lying in bed with the bed in the highest position and the left one fourth side rail down, contrary to the care plan and physician order. Certified Nursing Assistant 2 confirmed that the side rail should have been up and that the patient required it for mobility and fall prevention. Further interviews with nursing staff confirmed that beds should not be left in a high position unattended and that the care plan required the side rail to be up while the patient was in bed. Review of facility policy indicated that comprehensive care plans with patient-specific interventions must be implemented. The failure to follow the care plan and physician order for side rail use constituted the deficiency.
Plan Of Correction
C835: T22 DIV5 CH3 ART3- 72311(a)(2) Nursing Service - General Corrective action for resident found to have been affected by this deficiency: On 3/10/2025, both rails were verified to be up by DSD for resident 5. Identify any other residents who may have been affected by the deficient practice: On 3/10/25, ADONS and DSD performed rounds of the entire facility to ensure that any patients who had orders for side rails were following MD orders and adhering to the care plan. There were no other issues identified. Measures that will be put into place to ensure that this deficiency does not recur: Beginning 3/10/2025, DSD initiated in-servicing of CNA and licensed nursing staff regarding ensuring side rails are being utilized in accordance with physician's orders and patient plan of care. (To continue page 3 of 25) Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: Beginning 3/10/25, DSDS will perform weekly rounds of all in-house patients to ensure that if side rails are ordered, they are in place as per MD orders and plan of care. These audits will continue for 1 month or until substantial compliance is obtained. Any ongoing issues will be reported by DSD at the monthly QA meeting. Date of corrective action would be completed: 04/03/25