Failure to Update Care Plan After Bed Siderail Discontinuation
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan to reflect the discontinuation of bed siderails, as required by facility policy and regulatory standards. The facility’s bed rail policy stated that when the interdisciplinary care plan team determined a bed rail reduction was warranted, a bed rail assessment would be initiated and, if appropriate, the care planning process would be used to facilitate removal of the bed rails. The comprehensive care plan policy required that care plans be updated as needed based on occurrences and changes relevant to the resident’s care. For one resident with diagnoses including primary generalized osteoarthritis, idiopathic peripheral autonomic neuropathy, and type 2 diabetes, the Minimum Data Set documented intact cognition, no use of bed rails, and a need for partial/moderate assistance with bed mobility and transfers. This resident’s comprehensive care plan for falls, initiated earlier and revised at a later date, documented that the resident was at risk for falls due to bilateral above-knee amputations and included an intervention to encourage use of side rails to promote bed mobility. A physician’s order had been in place for two half side rails as enablers and was later discontinued. An occupational therapy progress note documented that the resident was screened for removal of bed siderails, that the resident could perform functional bed mobility without siderails with extensive assistance of one person, and that the interdisciplinary team agreed to remove the bilateral bed siderails. Observations on two separate days confirmed that the resident no longer had siderails on the bed, and the resident reported they had been evaluated and the siderails removed over a month prior. Despite these changes and team agreement, the comprehensive care plan was not revised to remove the intervention encouraging siderail use, leaving the care plan inconsistent with the resident’s current status.
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