Failure to Develop Comprehensive Care Plans for Siderail Use and Contact Isolation
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, specifically regarding the use of bed siderails and contact isolation precautions. For three residents who used bed siderails, the care plans did not address the use of these devices, despite physician orders and observations confirming their use. Staff interviews and record reviews revealed that the care plans lacked interventions to address the risks associated with siderail use, such as entrapment, and did not provide guidance for staff on prevention or response to such incidents. Facility policy required a bedrail evaluation and care plan reflecting that evaluation, but this was not completed for the affected residents. Additionally, one resident placed on contact isolation due to a multidrug-resistant organism (MDRO) infection did not have a comprehensive care plan addressing the isolation precautions. The resident's care plan did not include person-centered interventions or goals related to managing care needs while on contact isolation. Staff interviews confirmed that the required care plan was not developed, and facility policy mandated that such a plan be created within seven days of the comprehensive assessment. The deficiencies were identified through interviews, record reviews, and direct observations. Staff, including MDS coordinators and nursing leadership, acknowledged the absence of required care plans and interventions for both siderail use and contact isolation. Facility policies and procedures reviewed during the investigation confirmed the expectation for comprehensive, measurable, and timely care plans to address each resident's specific needs, which was not met in these cases.