Failure to Implement and Maintain Siderails as Indicated by Evaluation and Physician Orders
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents, specifically regarding the use of siderails for two residents with significant medical needs. For one resident with a history of seizures and ventilator dependence, a siderail evaluation conducted on May 24, 2025, indicated the need for siderails as a safety precaution, and a physician order was obtained the same day. However, this order was discontinued the following day and not renewed prior to the resident experiencing a fall from bed on June 2, 2025. Staff interviews and record reviews confirmed that the resident was found on the floor without siderails in place, despite the evaluation indicating their necessity. The Unit Manager and DON both verified that the physician order for siderails was not in effect at the time of the fall, and staff could not explain why the order had been discontinued. For another resident with chronic respiratory failure and ventilator dependence, a siderail evaluation completed on March 13, 2025, indicated the need for siderails. However, there was no physician order for siderails until April 8, 2025, leaving a gap between the evaluation and the implementation of the safety intervention. Staff interviews confirmed that the expectation was for nursing staff to obtain a physician order for siderails immediately following a positive evaluation, but this did not occur in a timely manner for this resident. Facility policy required that nursing staff complete a siderail evaluation, obtain a physician order, and implement siderails when medically necessary. The failure to follow these procedures resulted in residents not having siderails in place as indicated by their assessments, and in one case, directly preceded a fall from bed. Staff interviews consistently acknowledged the expectation to check evaluations, obtain orders, and implement siderails, but these steps were not consistently followed.