Failure to Complete Initial Side Rail Assessment Prior to Installation
Penalty
Summary
The facility failed to assess a resident for the use of side rails prior to their installation. A resident with diagnoses including dementia with behaviors, bipolar disorder, polyneuropathy, and anxiety disorder was readmitted to the facility and had a physician's order for 1/4 side rails to promote independence. Documentation showed that side rails were installed and in use, and the treatment administration record was signed off by a nurse. However, review of the resident's electronic medical record revealed that the required initial side rail assessment was not completed prior to the installation of the side rails. The only assessment found was a quarterly assessment marked as 'in progress' and dated after the installation. Interviews with facility staff, including the Maintenance Director, Unit Manager, and Director of Nursing, confirmed that there was no documented initial side rail assessment before the side rails were installed. Staff interviews revealed confusion regarding responsibility for ensuring the assessment was completed, with the Maintenance Director stating he did not verify assessments and the Unit Manager and Director of Nursing acknowledging the assessment was not done. The Administrator, who was new to the facility, was not familiar with the side rail policy but expected the assessment to be completed prior to installation.