Failure to Update Care Plan to Reflect Current Bed Placement and Side Rail Use
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to accurately reflect current care needs. The resident, who was moderately cognitively impaired, had a care plan indicating the bed should be placed against the wall for increased living space and that a full side rail should be used for ease of mobility and transfers. However, multiple observations over several days showed that the resident's bed was not against the wall and only a quarter rail was present on the middle right side of the bed. The care plan did not document the use of a quarter rail, nor did it reflect the actual bed placement. Staff interviews confirmed that the care plan was outdated and did not match the resident's current environment or equipment in use. The Resident Care Manager and LPN acknowledged that the care plan was not updated to reflect the use of a quarter rail or the change in bed placement, and the Chief Nursing Officer stated that it was her expectation that care plans should be updated to reflect current care needs. This discrepancy was identified through observation, interview, and record review.