Inaccurate Resident Assessments Related to Bedrail Use
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status regarding the use of bedrails. For four residents, the Minimum Data Set (MDS) assessments were coded to indicate daily use of bedrails as restraints, despite documentation in care plans and side rail assessments that the bedrails were used for mobility, independence, or at the resident's discretion. In several cases, care plans and assessments noted that the bedrails were not used as restraints, and residents or their representatives were informed of the risks and had provided consent for their use. However, the MDS continued to be coded as if the bedrails were restraints. Staff interviews, including statements from the Director of Nursing (DON) and Licensed Social Worker (LSW), confirmed that the MDS coding did not accurately reflect the actual use of bedrails for these residents. The DON stated that the coding was based on daily use of the side rails, not on whether they functioned as restraints, and expressed concern about falsifying records. This inconsistency between the MDS coding and the documented purpose and use of bedrails resulted in inaccurate assessments for the affected residents.