Incomplete Baseline Care Plan for Side Rail Use
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's Baseline Care Plan was complete and accurate regarding the use of half side rails. The resident, who had diagnoses including lymphedema of the left lower extremity, colon cancer, and dementia, was observed with half side rails on both sides of the bed and reported having experienced falls since admission. Documentation showed that an assessment and consent for side rail use was completed, indicating the rails were needed as an enabler due to the resident's weakness, and that the rails were to assist with transfers and bed mobility. However, the Baseline Care Plan did not include any information about bed mobility limitations or the need for half side rails. Further review revealed that the admission MDS assessment was still in progress, and while the comprehensive care plan later identified a risk for falls and interventions such as offering a different bed, the initial Baseline Care Plan failed to address the use of side rails. Interviews with facility leadership confirmed that the side rails had been in place since admission and that there should have been an order and documentation for their use in the Baseline Care Plan, as required by facility policy.