Failure to Maintain Accurate Care Plans and Assessments for Bedrail Use
Penalty
Summary
The facility failed to maintain accurate resident care plans and conduct ongoing assessments regarding the use of bedrails for three residents. For each resident, the clinical records did not include ongoing assessments for bedrail or enabler bar usage, nor did they contain the development of goals and interventions related to this equipment in the care plans. Observations confirmed the presence of bedrails or enabler bars in use, but physician orders were either missing or not reflected in the care plans. Specifically, one resident with diagnoses including high blood pressure, hemiplegia, and depression was observed with enabler bars on the bed, but there was no physician order or care plan documentation for their use. Another resident with cancer, high blood pressure, and anxiety had a physician order for bilateral assistive handrails, but the care plan lacked ongoing assessment and interventions. A third resident with high blood pressure, dementia, and anxiety also had physician orders for assistive handrails, but again, the care plan did not include ongoing assessment or related interventions. Facility policy required evaluation of potential risks associated with bedrail use, including entrapment, prior to installation, and ongoing assessment using a safety checklist. However, review of the clinical records and staff interviews confirmed that these requirements were not met for the three residents in question. The deficiencies were identified through observations, policy review, clinical record review, and staff interviews, and were communicated to the facility's Director.