Failure to Maintain Person-Centered Bed Rail Care Plans and Monitoring
Penalty
Summary
The facility failed to ensure that bed rail care plans for three residents were adequately reviewed and revised to be person-centered and to meet their medical needs. For each of these residents, the care plans included interventions such as documenting the use of bed rails as enablers, ensuring valid consent, and obtaining physician orders. However, the care plans lacked documentation of monitoring and supervision during bed rail use, ongoing assessment to confirm the bed rail continued to meet the resident's needs, evaluation of risks, identification of the person responsible for discontinuing the bed rail, and interventions to address any adverse effects from bed rail use. Observations and record reviews revealed that, despite care plans specifying the use of a single bed rail as an enabler, one resident was observed with bilateral bed rails in the up position. Interviews with the DON confirmed these findings. The deficiencies were discussed with facility leadership during the survey process, and the lack of comprehensive, individualized care planning and monitoring for bed rail use was consistently identified across the reviewed cases.