Failure to Revise Care Plan After Removal of Side Rails
Penalty
Summary
The facility failed to revise the care plan for a resident after the removal of side rails from her bed. The resident, who had diagnoses including congestive heart failure, morbid obesity, and anxiety disorder, was cognitively intact and had previously expressed a desire to have side rails to promote independence. The care plan, last updated in June, still listed side rails as an intervention for mobility impairment, despite their removal. Audits by the speech-language pathologist indicated the care plan had been updated, but the intervention remained unchanged in the documentation. Observations on July 8 confirmed that the resident's bed no longer had side rails, and the resident reported that the rails were removed during a hospitalization and not returned, with no alternative assistive device provided as promised. The DON confirmed the side rails were removed per protocol after the resident's hospital discharge and stated that side rails would not improve the resident's bed mobility. The failure to update the care plan to reflect the removal of side rails constituted the deficiency.