Damaged Side Rail Pads Not Replaced for Dependent Resident
Penalty
Summary
The facility failed to ensure that both side rail pads on a resident's bed were free from damage, wear, and tear. Observation revealed that the resident, who was admitted with diagnoses including unspecified dementia and senile degeneration of the brain, was lying in bed with half-length bilateral side rails that had ripped and damaged pads. The resident's care plan required the use of padded side rails as an enabler for bed mobility and to minimize the risk of bruising or skin tears, with instructions for nursing staff to periodically check the side rails for safety and refer to maintenance as needed. A physician's order also specified the use of padded side rails to prevent skin injury. Record review indicated that the resident was severely cognitively impaired and fully dependent on staff for all activities of daily living. During an interview, the ADON acknowledged that the side rail pads needed to be changed and should not be ripped or damaged to maintain the resident's safety and dignity. The facility's policy required staff to report any defective equipment to supervisors and document it in the maintenance request log, but this was not followed in this instance.