Failure to Complete Restorative and Bed Rail Assessments for Resident With Limited ROM
Penalty
Summary
The deficiency involves the facility’s failure to complete required restorative and bed rail assessments upon admission and with changes in condition for a resident with limited mobility and range of motion (ROM). The resident, who has diagnoses including acute and chronic respiratory failure with hypoxia, anxiety disorder, end stage renal disease, and anemia, reported that she previously had bilateral side rails to assist with bed mobility, but after a bed change they were removed. She stated she received a left side bed rail about a week prior to the survey and had repeatedly asked staff for a right side bed rail to help with repositioning and scooting up in bed. She demonstrated that she was unable to use her left arm, could grasp only with her right hand, and could not turn or reposition herself without a right side bed rail. Interviews and record review showed that the restorative nurse acknowledged that side rails were placed per the resident’s request on 3/3/26 and that no restorative assessment had been completed, despite the facility policy requiring restorative screening upon admission, quarterly, and with any significant change in function. The DON confirmed that a restorative assessment and care plan should be completed upon admission, quarterly, and as needed for changes. Occupational therapy documentation from 2/6/26 indicated the resident had bilateral side rails and used them for bed mobility with partial/moderate assistance, and therapy recommendations dated 2/16/26 included passive ROM to the left upper extremity, active ROM to the right upper and lower extremities, and bed mobility (rolling left and right). Facility policies required assessment for restorative programs and bed rails/side rails upon admission, quarterly, and upon significant change, using a Restorative Comprehensive Assessment/Side rail review, but this process was not completed for this resident as required.
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