Failure to Care Plan for Assistive Bed Devices for Bed Mobility
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a complete, person-centered care plan addressing a resident’s need for assistive bed devices, specifically side rails for bed mobility. A resident with acute and chronic respiratory failure with hypoxia, anxiety disorder, end stage renal disease, and anemia reported that she previously had bilateral side rails and used them for bed mobility, but after a bed change she no longer had both rails. She stated she had received only a left side bed rail over a week prior and had repeatedly asked staff for a right side bed rail to help with repositioning and scooting up in bed. During interview, the resident demonstrated she was unable to use her left arm and could only grasp with her right hand, and that she could not turn or reposition herself without a right side bed rail. Staff interviews and record review showed that the facility did not complete the required restorative assessment or update the care plan to reflect the resident’s need for assistive bed devices. The Restorative Nurse stated that side rails were placed per the resident’s request on a specific date but acknowledged that no restorative assessment was completed, even though such assessments and corresponding care plan updates should occur on admission, quarterly, and as needed. Occupational therapy documentation from an earlier treatment encounter indicated that the resident had bilateral side rails and used them effectively for bed mobility. The DON confirmed that her expectation is that care plans be completed on admission, quarterly, and as needed when changes occur, and the facility’s care plan policy requires development of a baseline, person-centered care plan within 48 hours of admission, including ADL needs. Despite these requirements and the documented and observed need for bilateral side rails, the care plan did not fully address the resident’s assistive bed device needs.
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