Failure to Maintain Padded Side Rails per Care Plan and Physician Orders
Penalty
Summary
The facility failed to implement and maintain fall risk and seizure care plans for three residents who had physician orders and care plan interventions requiring padded side rails while in bed. Observations revealed that for each of these residents, the required padding was either missing or not properly in place on one or both side rails during multiple surveyor visits. In one instance, a resident with epilepsy was found in bed with only one side rail padded, despite care plan and physician orders specifying bilateral padding for seizure safety. Another resident, with diagnoses including seizures and muscle wasting, was observed with one side rail unpadded, and a CNA admitted to removing the padding and forgetting to replace it. A third resident, with hemiplegia and a history of cerebral infarction, was found with the padding for one side rail on the floor rather than on the rail as required. Record reviews confirmed that all three residents had current care plans and physician orders specifying the use of padded side rails for safety, either due to seizure risk, fall risk, or to protect skin integrity. The care plans included measurable goals and interventions, such as maintaining bilateral padded side rails while in bed and monitoring for placement and safety every shift. Despite these documented requirements, staff did not consistently ensure that the padding was in place as ordered. Interviews with nursing staff, including RNs and CNAs, acknowledged the expectation that padding should always be present on the side rails when residents are in bed, and that staff are responsible for checking and maintaining this safety measure. Staff described processes for rounding and monitoring, but also admitted to lapses such as forgetting to replace padding after removal. The facility's policy requires comprehensive care plans with measurable objectives and timely interventions, and staff are to be notified of their responsibilities, but these procedures were not consistently followed for the residents in question.