Failure to Include Bed Rail/Grab Bar Use in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for four residents who were observed to use bed rails or grab/transfer bars. Despite the presence of these devices on the residents' beds, their use was not documented in the care plans as either an intervention or a focus area. This omission was identified through observations, interviews, and record reviews, which showed that the care plans did not specify the use of grab/transfer bars or bed rails, nor did they address the need for assessment, consent, or individualized interventions related to these devices. The residents involved had significant medical histories and functional limitations. For example, one resident had diagnoses including atrial fibrillation, aphasia, dementia, and required substantial assistance with mobility and self-care. Another resident had a history of fractures, reduced mobility, repeated falls, and required assistance with transfers and ambulation. Despite these complex needs and the use of assistive devices such as grab/transfer bars, the care plans only included general interventions related to mobility, therapy, and fall risk, without specific mention or planning for the use of bed rails or grab/transfer bars. Staff interviews revealed a lack of awareness regarding facility policy on the use of grab/transfer bars, with uncertainty about whether assessments or consents were required and whether these devices should be included in care plans. The Director of Nursing and Administrator both indicated that grab/transfer bars were standard on most beds and did not consider them a safety risk or restraint, and therefore did not see the need for assessment or care planning. However, the facility's own policy required comprehensive, person-centered care plans that address all resident needs, including measurable objectives and interventions derived from thorough assessment, which was not followed in these cases.