Failure to Follow Physician Orders and Proper Use of Bed Rails
Penalty
Summary
The facility failed to ensure the proper use and adherence to physician's orders regarding bed rails for six residents. In multiple instances, residents were observed with bed rails in the half-length position when physician orders specified quarter-length rails. This discrepancy was confirmed through interviews with nursing staff and the Director of Nursing, who acknowledged that the bed rails in use did not match the orders. Additionally, some staff members demonstrated a lack of understanding regarding the differences between quarter, half, and full side rails, further contributing to the improper use of bed rails. Several residents involved had significant cognitive impairments and were dependent on staff for most activities of daily living, including transfers, hygiene, and dressing. The residents had diagnoses such as dementia, Alzheimer's disease, depression, schizophrenia, osteoporosis, hemiplegia, and sepsis. Care plans and physician orders for these residents consistently indicated the need for quarter-length side rails to assist with mobility and repositioning, with instructions to monitor for potential entrapment. However, observations revealed that half-length rails were used instead, and the required monitoring and risk assessments were not adequately performed or documented. As a result of these failures, one resident experienced an incident where they became trapped on the bed rail, resulting in a cut on the nose bridge and a precarious position with the upper body off the bed and head touching the floor. The facility's own policies required a person-centered approach, correct installation, and maintenance of bed rails, as well as adherence to physician orders. The lack of compliance with these policies and orders placed multiple residents at risk for entrapment and injury.