Failure to Prevent Injury from Side Rail Use in Resident with Behavioral Risks
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia with behavioral disturbances, and a history of grabbing behaviors was not adequately protected from injury related to side rail use. The resident was non-ambulatory, dependent on staff for all activities of daily living, and exhibited daily grabbing behaviors, including grabbing side rails during care and transfers. The care plan identified the resident's behavioral risks and directed staff to monitor and intervene before agitation escalated, but did not include specific interventions to prevent injury from side rail use, despite staff being aware of the resident's tendency to grab the rails. Multiple nursing assistants reported that the resident consistently grabbed the side rails during care, sometimes requiring them to place a pillow between the resident and the rails to prevent injury. On one occasion, a nursing assistant observed the resident's hand stuck between the bars of the side rail but did not notify a nurse, as this was a frequent occurrence. The facility's documentation and interviews confirmed that the resident's right hand and fingers were found swollen and bruised, with an x-ray revealing an acute nondisplaced fracture of the fifth finger. The injury was determined to have occurred when the resident's hand became trapped in the lower opening of the side rail, aligning with the observed bruising. Despite the known risk behaviors and repeated incidents of grabbing the side rails, the care plan lacked interventions such as padding or removal of the side rails to prevent injury. Facility leadership, including the Director of Nursing and Assistant Director of Nursing, acknowledged awareness of the resident's behaviors but could not explain why preventive measures were not implemented prior to the injury. The facility's behavior management policy required maintaining a safe environment, but this was not achieved in this case, resulting in the resident sustaining a fracture.