Failure to Update Care Plan for Side Rail Use
Penalty
Summary
The facility failed to revise the care plan for one resident after a change in the use of side rails. According to the facility's own policies, care plans are to be updated as needed, including when side rails are used for safety or positioning. The resident in question was admitted with diagnoses of dysphagia, hypertension, and moderate protein-calorie malnutrition, and was assessed as cognitively intact. The comprehensive care plan documented the use of bilateral 1/4 upper side rails at the request of the resident's representative, with no mention of lower side rails being used. However, during multiple observations, the resident was found in bed with both upper and lower 1/4 side rails in the up position. Staff interviews confirmed that all four side rails were being used, and the resident himself confirmed his preference for this arrangement to aid in mobility. Despite this, the care plan was not updated to reflect the actual use and resident preference for four side rails, as confirmed by the DON and an LPN. This failure to revise the care plan as required constitutes the deficiency.