Failure to Reassess Bed Rail/Grab Bar Need After Resident Readmission
Penalty
Summary
The deficiency involves the facility’s failure to reassess a resident for the use of bed rails/grab bars upon readmission, as required by its own policy. During an unannounced Quality-of-Care complaint investigation, a resident with Parkinson’s disease and mild cognitive impairment was observed sitting in a wheelchair at bedside with no side rails or grab bars attached to the bed. Review of the resident’s prior bed rail assessment from June 11, 2025, showed documented bed mobility issues, including difficulty moving in bed, moving to a sitting position, and maintaining standing/sitting balance. That assessment also recorded that the resident’s representative reported the resident had fallen at home and requested grab bars, with recommendations for left and right grab bar assistance. Record review showed the resident had been transferred to a general acute care hospital on November 12, 2025, and readmitted on November 16, 2025. There was no documented evidence that the resident was reassessed for the use of bed rails or grab bars following this readmission, and the resident did not currently have grab bars on the bed. In interviews, the DON stated that facility policy requires assessment for bed rails upon admission, readmission, and at the request of the resident/representative or nursing staff, and acknowledged that the resident was not reassessed for grab bar use after readmission despite this policy. The facility’s written policy on proper use of bed rails requires reassessments at least quarterly and upon a significant change in status, but this was not carried out for the resident after returning from the hospital.
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