Failure to Assess and Care Plan for Side Rail Use
Penalty
Summary
The facility failed to properly assess and document the use of side rails for two residents, resulting in deficiencies related to resident safety and care planning. For one resident with diagnoses including dementia, hypertension, and chronic kidney disease, observations showed the resident using two upper half side rails while in bed. Despite the resident's cognitive impairment and need for substantial to maximal assistance with bed mobility and transfers, there was no current side rail assessment, no physician order for side rail use, and no care plan addressing side rails since the resident's admission. The last side rail assessment on record was from a previous admission, and staff confirmed that no updated assessment or care plan had been completed for the current stay. Another resident, admitted with multiple complex medical conditions such as end stage renal disease and vertebral fractures, was also observed with two upper side rails in use. This resident required total or partial assistance with most activities of daily living and was dependent for transfers. Although a side rail assessment was present in the electronic health record, there was no care plan addressing the use of side rails. Staff interviews confirmed that side rail use should be included in the care plan and that assessments should be completed and reviewed regularly, but this was not done for the resident in question. The facility's own policy requires that alternatives to bed rails be attempted and documented, that a risk versus benefit assessment be completed, and that informed consent be obtained prior to installation. The policy also mandates that the use of side rails be addressed in the resident's care plan, including details on medical need, monitoring, and interventions to minimize risks. These steps were not followed for the two residents, as evidenced by the lack of assessments, care plans, and documentation of alternatives or informed consent.