Failure to Develop Person-Centered Care Plans for Side Rail Use and Hearing Aid Management
Penalty
Summary
The facility failed to develop person-centered care plans for two residents in key areas. For one resident with Alzheimer's Disease, the Side Rail Use assessment indicated a request for side rails to assist with turning, repositioning, and transfers due to weakness. Despite repeated observations of the resident in bed with side rails in place, the care plan reviewed and updated did not include any documentation or plan for the use of side rails for positioning. Interviews with the MDS Nurse, DON, and Administrator confirmed that the MDS Nurse was responsible for care plan development and acknowledged that a care plan for side rail use should have been in place but was not. Another resident with dementia and behavioral disturbances was observed using hearing aids, although the most recent MDS assessment coded the resident as having adequate hearing without hearing aids. The care plan did not address hearing loss or the use of hearing aids, despite multiple observations of the resident using them and the resident's own statements about their use. The MDS Nurse stated she was unaware of the resident's use of hearing aids and had not developed a care plan for this need. Both the DON and Administrator confirmed that the MDS Nurse was responsible for ensuring care plans addressed hearing loss and hearing aid use, which had not occurred in this case.