Failure to Develop and Implement Person-Centered Care Plans for Bed Rail Use
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents regarding the use of bed side rails. For one resident with spastic hemiplegia and muscle weakness, mobility rails were observed in use on both sides of the bed, but there was no care plan specifically addressing their use. Both the LVN and MDS nurse confirmed that the resident's care plan did not include a dedicated section for mobility rails, despite their role as an assistive device requiring monitoring for safe usage. The DON also acknowledged that the use of mobility rails was only listed as an intervention under another care plan and not as a separate, specific plan as required. For another resident with a history of seizure disorder and severe cognitive impairment, padded side rails were observed in use during multiple observations. The resident's physician orders included seizure precautions and specified the use of padded rails. However, review of the care plan revealed that the intervention for padded side rails was not included. The LVN and DON both stated that the care plan should have included this intervention to ensure staff awareness and proper care for the resident. Facility policy requires that comprehensive, person-centered care plans be developed within a specified timeframe after assessment and be revised as resident conditions change. The lack of specific care plans for the use of mobility and padded side rails for these two residents was confirmed through interviews, record reviews, and direct observation, constituting a failure to meet the facility's own policies and regulatory requirements.