F0657

E

Failure to Include Bed Rail Use in Comprehensive Care Plans

Cary, North Carolina Survey Completed on 12-31-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to update and include the use of bed rails in the comprehensive care plans for four residents who were using them. For each of these residents, bed rail assessments and MDS assessments documented the presence and use of bed rails as enablers to promote independence, and residents reported using the rails to assist with rolling in bed and moving from lying to sitting. Observations on multiple dates showed various types of bed rails (half-circle and rectangular, unilateral and bilateral) in the raised position on the residents’ beds. Despite this, the most recently reviewed care plans for these residents did not contain any care plan problem, goal, or interventions addressing bed rail use.

Resident #1 was cognitively intact with lower extremity impairment and used a left-side half-circle bed rail to assist with rolling and sitting up, but his care plan lacked any bed rail interventions. Resident #6 was severely cognitively impaired with lower extremity impairment and used a left-side rectangular bed rail as an enabler, yet his care plan also did not address bed rails. Resident #41, cognitively intact with no extremity impairment, had bilateral rectangular bed rails raised and used them for repositioning and moving to sitting, but her care plan contained no bed rail information. Resident #49, cognitively intact with no extremity impairment, had bilateral half-circle bed rails raised and used them for rolling and sitting up, with no corresponding care plan entry. Interviews with Nurse #1, the DON, the MDS Nurse, and the Administrator revealed that the MDS Nurse was responsible for updating care plans and that facility leadership and the MDS Nurse were unaware that the “grab bars” in use were considered bed rails that needed to be included in the comprehensive care plans.