Failure to Assess and Care Plan for Bedrail Use
Penalty
Summary
The facility failed to maintain accurate resident care plans and conduct ongoing assessments regarding the use of bedrails for four residents. Observations revealed that each of these residents had enabler bars (bedrails) present on their beds, but their clinical records did not include ongoing assessments for the use of these devices. Additionally, the care plans for these residents did not contain goals or interventions related to bedrail usage, despite the presence of physician orders in some cases. The residents involved had various medical conditions, including hyponatremia, cancer, malnutrition, high blood pressure, Friedreich ataxia, hyperkalemia, anxiety, and bipolar disorder. The lack of documentation and assessment was confirmed by the Director of Nursing, who acknowledged that the facility did not ensure bedrails were used to meet residents' needs or address the associated risks as required by regulation.