Failure to Complete Required Assessments and Documentation Prior to Side Rail Installation
Penalty
Summary
The facility failed to follow required procedures before installing side rails for a resident diagnosed with Parkinson's disease. The resident was observed on multiple occasions with bilateral quarter length side rails in the raised position, yet there was no documentation of an assessment for side rail use, no evaluation of entrapment risk, no signed informed consent, no physician's order, and no care plan addressing side rail usage. The resident's medical record and care plan did not reflect the presence or use of side rails, and the quarterly MDS assessment indicated the resident did not have side rails as a restraint and was independent with bed mobility. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for side rail assessments. The Unit Manager stated she had never completed a nursing side rail assessment, while the ADON indicated that therapy should evaluate residents first, followed by a nursing assessment, consent, physician's order, and care plan update. However, neither therapy nor nursing staff had completed these steps for the resident in question. The Director of Therapy and Physical Therapist both stated they did not perform side rail assessments, and the Administrator was unable to explain why the required assessments and documentation were not completed for this resident.