Failure to Obtain Physician Order and Care Plan for Bed Rail Use
Penalty
Summary
The facility failed to ensure that a resident using bed side rails had a physician's order in place and that the use of side rails was incorporated into the resident's care plan. According to the facility's own policy, bed rails require a physician's order specifying the reason for use, and this intervention must be added to the care plan and reviewed regularly by the interdisciplinary team. Record review for a resident with diagnoses including peripheral vascular disease and heart failure, and with moderately impaired cognition, showed that side rails were being used for turning and repositioning in bed. Despite observations confirming the resident's use of upper quarter side rails and staff interviews acknowledging this use, there was no physician's order documented for the side rails, nor was their use addressed in the resident's comprehensive care plan. Multiple staff members, including a CNA, LPN, MDS Coordinator, and DON, confirmed during interviews that the required order and care planning for side rail use were missing.