Failure to Notify Designated Representative of Side Rail Discontinuation
Penalty
Summary
Surveyors found that the facility failed to notify a resident’s designated representative when a treatment was discontinued, as required by facility policy and regulation. The facility’s policy on Physician Orders, revised January 2025, stated that the resident and/or designated representative would be updated on any medication or treatment changes. One resident with diagnoses including dementia, Alzheimer’s disease, and lack of coordination had a severe cognitive impairment per a recent MDS, required supervision or touching assistance for bed mobility, and setup assistance for transfers. This resident had a physician’s order dated 09/06/2025 for two half side rails for bed mobility, and the comprehensive care plan documented the use of two half side rails to enable bed mobility. On 10/16/2025, an OT progress note documented that the resident was screened by rehabilitation for removal of bed siderails to maintain a safe environment and promote overall quality of life, and a physician’s order on the same date directed discontinuation of the two half side rails. There was no documentation that the resident’s designated representative/power of attorney was notified of this change. During observation on 01/22/2026, the resident was seen in bed without side rails. In an interview, the designated representative stated they were not informed of the removal until they arrived for a visit and observed staff in the process of removing the side rails, and expressed that they would have liked to participate in the decision-making process. The Director of Rehabilitation stated they assessed the resident for side rail removal but did not inform the representative, indicating that unit nurses were responsible for notifications. The DON stated that if there was a change in treatments or nursing interventions, the designated representative should have been informed.
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