Failure to Care Plan for Resident Use of Bed Grab Bars
Penalty
Summary
The facility failed to develop a person-centered care plan with measurable objectives and interventions addressing one resident’s use of bed grab bars/side rails. The resident had diagnoses including generalized muscle weakness, dementia, and chronic atrial fibrillation, and was documented as having severely impaired cognition on the MDS, as well as lacking capacity to understand and make decisions per the H&P. The resident was dependent on staff for toileting, bathing, and lower body dressing and had a responsible party identified. On observation, the resident was seen in bed with bilateral grab bars in place, which RN staff stated were used to aid in bed mobility and repositioning. Record review on the same date showed there were no physician orders for grab bars and no care plan addressing the use of grab bars or side rails from 10/26/2022 through the date of review. RN 1 acknowledged that, because the resident used grab bars for mobility and repositioning, a care plan should have been developed to reflect this use and to communicate to licensed nurses and CNAs the need to visually monitor the resident’s use of the grab bars, the condition of the equipment, and safety concerns such as entrapment. The DON similarly stated that a care plan should have been developed to indicate the reason for the grab bars and the interventions needed to minimize safety risks, including monitoring the resident’s position in bed and the working condition of the grab bars. The facility’s care plan policy required a comprehensive, person-centered care plan with measurable objectives and timetables to meet each resident’s needs, which was not implemented for this resident’s use of side rails.
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