Care Plans Lacked Bed Rail Usage Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that the care plans for two residents included directives for the use of bed rails, despite physician orders and nursing evaluations indicating their necessity. One resident with dementia and contractures had a physician order for half side rails and a nursing evaluation recommending bilateral side rails as enablers to promote independence. However, the resident's care plan did not document the use of side rails. Similarly, another resident with dementia and anxiety disorder had a physician order for bilateral quarter side rails and a nursing evaluation supporting their use, but the care plan lacked any mention of side rail usage. Observations confirmed that bed rails were in use for both residents, yet their care plans did not reflect this intervention. The Director of Nursing acknowledged that the care plans should have included side rail usage and could not explain the omission. Facility policy required documentation of side rail use on the resident's plan of care following evaluation, but this was not followed for the residents in question.