Failure to Revise Care Plans for Bed Rail Use and Bed Mobility
Penalty
Summary
The deficiency involves the facility’s failure to revise and update care plans to reflect residents’ current needs and the use of bed rails. For one resident with morbid obesity, muscle weakness, lack of coordination, and a need for assistance with personal care, the care plan revised on 11/11/25 did not include any interventions for the use of bed rails, despite quarter-size bed rails being present on both upper sides of the bed and the resident confirming she used them for positioning and mobility. Another resident with major depressive disorder, insomnia, anxiety disorder, hyperlipidemia, and heart failure had a physician’s order, effective since 01/09/23, for quarter-size bed rails for mobility and transfers, and quarter-size bed rails were observed on both upper sides of the bed; however, the care plan revised on 11/11/25 contained no interventions addressing bed rail use. The DON confirmed that this care plan had not been revised to include bed rail use. A further deficiency was identified for a resident with esophagitis, anxiety disorder, anemia in chronic kidney disease, muscle weakness, end-stage renal disease, systolic congestive heart failure, and fatty liver, who was observed to be unable to turn and reposition without assistance and had quarter-size bed rails on both sides of the bed. The MDS dated 12/02/25 documented that this resident was dependent on staff for bed mobility, but the care plan dated 06/03/24 still stated the resident could turn and reposition independently, and the DON acknowledged the care plan should have been revised to reflect dependence on staff. Another resident with a history of falling, lack of coordination, hyperlipidemia, depression, need for assistance with personal care, and chronic systolic congestive heart failure was observed with bed rails in use, yet the care plan was not revised to indicate the use of quarter bed rails for bed mobility and transfers until 12/17/25. The DON confirmed that this care plan had not been updated prior to that date to reflect bed rail use.
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