Failure to Maintain Comprehensive Care Plans for Side Rail Padding and Repositioning Refusals
Penalty
Summary
The facility failed to ensure that the Resident Care Plan (RCP) was comprehensive for two residents, specifically regarding the use of side rail padding and documentation of refusals for repositioning. For one resident with vascular dementia, muscle weakness, and cachexia, physician orders directed the use of quarter side-rails for mobility and transfer. However, side rail evaluations were either incomplete or lacked specific details about the number and length of side-rails. Observations showed the resident in bed with double-sided Velcro pads on both side-rails, but neither the active physician's orders nor the RCP documented the use of side-rail padding. Additionally, the Nurse Aide Care Card did not mention the use of side-rails or padding, and the Director of Nursing Services (DNS) was unaware of the reason for the padding or its absence from care documentation. For another resident with type 2 diabetes, chronic pain, and edema, the RCP identified a risk for skin breakdown and included interventions such as turning and repositioning every two hours and use of pressure redistribution devices. Despite these interventions, wound care notes and staff interviews revealed that the resident frequently refused repositioning, offloading, and an out-of-bed schedule, which contributed to the worsening of a coccyx wound to a Stage 3 pressure ulcer. Staff interviews confirmed that refusals had been ongoing for months, but the RCP did not reflect these refusals until after surveyor inquiry. The wound nurse and nurse aide both acknowledged the resident's non-compliance with repositioning and the lack of documentation in the care plan. Facility policy required that ongoing changes in residents' status be updated by nursing or the interdisciplinary team as needed, and that care plans be revised accordingly. However, the care plans for both residents were not updated to reflect the actual care being provided or the residents' behaviors, resulting in incomplete and non-comprehensive care plans that did not meet regulatory requirements.