Failure to Maintain Accurate Care Plans and Assessments for Bedrail Use
Penalty
Summary
The facility failed to maintain accurate resident care plans and conduct ongoing assessments regarding the use of bedrails for two residents. Facility policy required an assessment to determine the need for side rails, including a review of the resident's bed mobility and transfer abilities, and mandated that the use of side rails as assistive devices be addressed in the resident's care plan. However, for both residents observed, the clinical records did not include ongoing assessments for enabler bar usage, nor did they contain the development of goals and interventions related to this usage in the care plans. One resident had diagnoses including high blood pressure, hyponatremia, and depression, while the other had hyperkalemia, dementia, and depression. Observations confirmed that both residents had two top enabler bars present on their beds. Staff interviews further confirmed that the facility did not maintain accurate care plans or conduct ongoing assessments to ensure that bedrails were used appropriately and that associated risks were addressed, as required by facility policy and state regulations.