Failure to Revise Care Plans for Side Rail Use
Penalty
Summary
The facility failed to revise the comprehensive care plans for three residents to accurately address the use of side rails. For each of these residents, the care plans documented the use of grab bars and quarter-sized side rails as the least restrictive interventions for bed mobility, turning, positioning, and transfers. However, the medical records and side/bed rail evaluations indicated that other alternatives, such as adjustable beds and bedside mats, were considered or attempted. The care plans did not reflect these alternatives or provide individualized interventions prior to the use of side rails. During interviews and medical record reviews, it was confirmed that the interventions related to the use of grab rails were the same across all three residents, and the care plans did not accurately document the least restrictive devices used. The admitting nurse initiated the care plans, but there was uncertainty regarding why the same interventions were applied to each resident and why the documentation did not align with the alternatives considered. This resulted in care plans that were not individualized to each resident's needs regarding side rail use.