Failure to Include Side Rail Use in Resident Care Plan
Penalty
Summary
The facility failed to develop an individualized, person-centered comprehensive care plan to address the use of side rails for a resident with chronic kidney disease stage 5 and generalized muscle weakness. The resident was admitted with significant mobility limitations, requiring partial to moderate assistance with bed mobility and substantial to maximal assistance with moving from lying to sitting. Despite being cognitively intact and using bilateral grab bars to assist with rolling over in bed, the resident's care plan did not reference the use of side rails. An assessment completed by a nurse indicated that the resident did not need or use side rails, and the most recent care plan review also omitted any mention of side rail usage. Observations confirmed that the resident was using bilateral grab bars, and the resident reported using them for assistance during care. Interviews with facility staff, including the MDS nurse, DON, and Administrator, revealed that the responsibility for updating the care plan with side rail usage information was understood but not executed. The omission was identified through observation, record review, and staff interviews, demonstrating a lack of comprehensive care planning for the resident's actual needs and equipment in use.