Failure to Assess, Document, and Care Plan Bedrail Use
Penalty
Summary
The facility failed to follow its own policy and regulatory requirements regarding the use of bedrails for four residents. Specifically, the facility did not obtain physician orders for the use of bedrails, did not assess residents for the risk of entrapment prior to installing bedrails, and did not update care plans to reflect the use of bedrails. These deficiencies were identified through observations, interviews, and record reviews. For each of the four residents reviewed, there was no documentation of a physician's order authorizing the use of bedrails, no entrapment risk assessment completed before installation, and no care plan developed to address the use of bedrails. The residents involved had varying medical histories, including chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder, acute kidney failure, cirrhosis of the liver, paraplegia, bipolar disorder, diabetes mellitus, morbid obesity, and muscle weakness. Cognitive assessments indicated that most residents had no or only moderate cognitive impairment, and none had upper or lower extremity impairments that would have necessitated bedrail use without proper assessment. Observations on multiple dates confirmed that the residents were in bed with bedrails in place, despite the lack of required documentation and assessments. Interviews with the DON confirmed the absence of physician orders, entrapment risk assessments, and care plans for all four residents using bedrails.