Failure to Implement Bed Rail Care Plan Interventions
Penalty
Summary
The facility failed to develop and implement care plans for the application of bed rails for three residents who had physician orders or care plan interventions specifying the use of side rails for assistance with bed mobility, transfers, or repositioning. For one resident, current orders indicated the use of bilateral upper side rails to assist with bed mobility and transfers, and the care plan included this intervention; however, observation revealed that no side rails were present on the bed. This finding was confirmed by the Director of Nursing (DON). Similarly, another resident had a fall care plan intervention for half bilateral side rails to the head of the bed to increase independence with positioning and personal care, but observation showed the resident lying in bed without the side rails in place as specified in the care plan. The DON confirmed the absence of side rails. A third resident had a care plan order for bilateral quarter side rails to assist with repositioning and bed mobility, but observation again revealed no side rails in place, which was acknowledged by the DON. These findings demonstrate that the facility did not implement the care plan interventions related to bed rail use as ordered for these residents.