Failure to Develop Care Plans for Bed Rail Use
Penalty
Summary
Facility B failed to develop and implement care plans addressing bed rail use for two of four residents reviewed for care planning. Observations showed that both residents were lying in bed with raised bilateral three-quarter bed rails, but their care plans did not include any information regarding the use of these bed rails. Review of the facility's policies indicated that the care planning team is responsible for creating individualized, comprehensive care plans based on resident assessments, and that these care plans should guide daily care routines and be accessible to staff. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, confirmed that the care plans for these residents did not reflect their use of bed rails, despite the expectation that such information should be included. The Administrator also acknowledged that residents with bed rails should have this reflected in their care plans. The lack of care plan documentation for bed rail use placed the residents at risk for unmet care needs and increased the risk of accidents.