Failure to Develop Comprehensive Care Plans for Bed Rail and CPAP Use
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents in the areas of bed rail use and CPAP machine usage. For one resident, although bilateral quarter length side rails were observed in use and the resident confirmed their ongoing use, the care plan did not include this intervention. The admission nurse had incorrectly documented that the resident did not use side rails, and the MDS nurse relied on this assessment without direct observation. Both the Director of Nursing and the Administrator acknowledged that the care plan should have included the use of side rails, but the omission occurred due to reliance on inaccurate documentation and automated care plan generation. For another resident, the facility did not include the use of a CPAP machine in the care plan, despite the resident bringing the device from home and using it nightly for sleep apnea. The admission nurse was unaware of the CPAP machine and did not note its presence during the assessment, and the MDS assessment also failed to capture this information. Staff interviews confirmed the resident's independent use of the CPAP machine, and the Administrator agreed that a care plan should have addressed this intervention. The deficiency resulted from a lack of direct observation and incomplete communication during the assessment and care planning process.