Failure to Develop Care Plan for Bed Siderail Use
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan addressing the use of bilateral bed siderails for a resident with multiple diagnoses, including encephalopathy, COPD, and unspecified dementia. The resident was assessed as having severely impaired cognitive skills and required moderate assistance to supervision for activities of daily living. Despite these needs, there was no physician order or care plan in place for the use of bed siderails, as confirmed by a review of the resident's records and care plan documentation. Observations on the specified date revealed the resident lying in bed with the bed siderails up. Both a registered nurse and the director of nursing acknowledged during interviews that a care plan and physician order should have been present for the use of bed siderails, especially since such devices may restrict movement and are considered restraints if the resident cannot remove them independently. Facility policies reviewed also indicated that care plans must be developed for any device that may restrict a resident's movement, but no such plan was found for this resident.