Failure to Timely Update Bed Rail Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the proper use and timely reassessment of bed rails for two residents who utilized side rails. For one resident with a history of arthropathic psoriasis, the side rail assessment was last updated several months prior to the observation, despite a physician's order for side rails to assist with bed mobility. The DON confirmed that the assessment had not been updated regularly or quarterly as required. Similarly, another resident with a cervical vertebra fracture had an outdated side rail assessment, with the last update occurring months before the observation, even though there was an active physician's order for side rails for bed mobility. The DON acknowledged that this assessment was also not updated according to the facility's schedule. The facility's policy requires that side rail assessments be completed at least quarterly, upon significant change in status, or when there is a change in the type of bed, mattress, or rail. However, both residents' assessments were not updated in accordance with this policy. These lapses were identified through observation, record review, and interviews with the DON, who verified the assessments were overdue. The failure to update side rail assessments as scheduled constituted a deficiency in the facility's adherence to its own procedures for the safe use of bed rails.