Failure to Accurately Assess and Document Side Rail Use
Penalty
Summary
The facility failed to accurately assess and document the appropriate use and number of side rails for a resident who was observed with bolsters, quarter side rails on both the upper and lower sections of the bed, and floor mats in the room. Staff interviews revealed that the resident was dependent on staff for mobility, unable to turn or get out of bed without assistance, and had cognitive impairments including confusion and impaired decision-making. Despite these conditions, there was inconsistency among staff regarding the intended use of the side rails and bolsters, with some staff unaware of the number of rails in use or the need for an assessment for the bolsters. The care plan did not specify the number of side rails to be used or include any mention of bolsters. Documentation provided by the facility included a consent form and assessment for the use of a quarter side rail as an enabler, but it did not specify the number of rails or address the use of bolsters. The care plan was updated to reflect the use of the device for the resident's independence and psychological well-being, but lacked details on the specific devices in use. The lack of clear assessment, documentation, and communication regarding the use of side rails and bolsters led to the deficiency identified during the survey.