Failure to Develop Care Plans for Residents Using Side Rails
Penalty
Summary
The facility failed to develop and implement person-centered care plans with measurable objectives and interventions for two residents who utilized side rails as mobility aids. For one resident with a history of traumatic brain injury and functional quadriplegia, records indicated severe cognitive impairment and total dependence on staff for daily activities. Despite physician orders and assessments recommending bilateral grab bars for mobility, there was no care plan in place to address the use of side rails, as confirmed by both observation and staff interviews. Similarly, another resident with generalized muscle weakness, bilateral hand contractures, and dementia required maximal assistance with daily activities and had an order for bilateral grab bars to aid in bed mobility and provide a sense of security. Observations and interviews confirmed the presence and use of grab bars, but a review of the electronic health record revealed that no care plan had been developed to address their use. Staff acknowledged the absence of care plans for both residents regarding side rail use. The Director of Nursing confirmed that care plans should have been developed for both residents to address their use of side rails as mobility aids. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timetables for each resident, but this was not followed for the two residents in question.