Failure to Implement Ordered Enabler Bars for Bed Mobility
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered enabler bars/side rails for a resident to assist with bed mobility as assessed and care planned by the facility. The resident was admitted with multiple serious diagnoses, including cellulitis with gangrene of both great toes, peripheral vascular disease, bacteremia, significant coronary artery disease, heart failure with preserved ejection fraction, end stage renal disease requiring hemodialysis, chronic combined systolic and diastolic CHF, angina, and multiple coronary stent placements. An admission MDS showed moderate cognitive impairment. An enabler assessment documented an order for half enabler bars on both sides of the bed for weakness, with stated benefits including aiding in maintenance of proper body alignment, posture for eating and breathing, appearance, and assistance with ADLs. The resident’s care plan included bilateral enabler bars for bed mobility, and physician orders for January documented bilateral assist bars/side rails to aid in bed mobility. Despite these assessments, care plan entries, and physician orders, the enabler bars were not implemented on the resident’s bed. Observation of the former room after the resident’s discharge showed the bed had no side rails or enabler bars in place. An LPN reported that the resident did not have enabler bars on the bed while residing at the facility. The Maintenance Director stated he had not received a work order to apply enabler bars after the resident transferred from the skilled unit to the LTC unit and confirmed he did not apply them. A RN confirmed the transfer date from the skilled unit to the LTC unit. The facility’s policy on proper use of side rails stated that side rails may be used to assist in mobility and transfer, that an assessment would determine the reason for use, and that use of side rails as an assist device would be addressed in the plan of care, which had been done for this resident but not carried out in practice.
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