Failure to Maintain Clean Side Rail Pads for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with hemiplegia, hemiparesis, insomnia, and dependence on supplemental oxygen was observed in bed with their face touching padded side rails that were visibly soiled with dry, yellow, and brown food stains. The resident's Minimum Data Set indicated moderately impaired cognitive skills and total dependence on staff for eating, toileting hygiene, and personal hygiene. During the observation, both the activity aide and a CNA confirmed that the side rail pads were dirty and acknowledged that the resident's face was in contact with the soiled pads while sleeping. Further interviews revealed that the facility's Quality Assurance Nurse stated side rail pads should be disinfected daily and as needed to prevent cross contamination and ensure resident safety and comfort. A review of the facility's infection prevention and control policy confirmed the requirement to maintain a safe, sanitary, and comfortable environment to prevent the development and transmission of disease and infection. The failure to keep the side rail pads clean resulted in an unsanitary environment and placed the resident at potential risk for infection.