Failure to Follow Physician Orders for Side Rails and Neurological Checks
Penalty
Summary
The facility failed to provide care in accordance with professional standards by not following physician orders for side rail implementation and neurological checks for four residents reviewed for fall interventions. Specifically, several residents had physician or care plan orders for bilateral or quarter side rails to assist with bed mobility and repositioning, but observations revealed that these side rails were not in place as ordered. The Director of Nursing confirmed in each case that the side rails were missing despite the documented orders and care plans. Additionally, a resident who experienced an unwitnessed fall did not receive neurological assessments as required by the facility's policy, which mandates a specific schedule of neuro checks following such incidents. The Director of Nursing acknowledged that these assessments were not performed for the resident after the unwitnessed fall, despite the policy and the resident's history of multiple falls. These findings were based on record reviews, staff interviews, and direct observations during the survey process.