Failure to Provide Ordered Bed Rails for Resident Mobility
Penalty
Summary
The facility failed to ensure that bed rails were in place as ordered to assist a resident with bed mobility. The resident, who had diagnoses including morbid obesity, muscle weakness, and Type II Diabetes Mellitus, was care planned and assessed to require bilateral half side rails to promote independence with bed mobility, self-positioning, and transfers. The physician order also specified half side rails on both sides of the bed. However, during observation, it was noted that only the left side of the bed had a grab bar, while the right side, which was against the wall, did not have one installed. The resident reported that both grab bars were necessary to assist with mobility during personal care in bed. The Maintenance Director confirmed the absence of the right-side grab bar, attributing it to the way the mattress fit the bedframe. Further interview revealed that the Maintenance Director had not assessed the mattress or bedframe for proper fit since beginning employment and had not made any changes to the resident's bed setup. This resulted in the resident not having the necessary equipment in place as indicated by their care plan and physician order.