State Findings:
Based on record review, review of the facility policy titled Care Plans, and staff interviews, the facility failed to develop and implement a care plan for assist rails for one resident (R) (#1) of 13 residents with bedrails.
On [DATE] a determination was made that the facility’s noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents.
The Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy (IJ) on [DATE] at 10:00 a.m. The noncompliance related to the IJ identified to have existed on [DATE] when R#1, who was not obese, received a standard low air loss (LAL) mattress which was placed on a bariatric bed (a large bed for the severely obese residents) leaving a gap between the mattress and assist rail.
The IJ is outlined as follows:
R#1 was admitted to the facility on [DATE] under Hospice services. R#1 had a room change on [DATE] and was placed on a bariatric bed with assist rails (the resident weighed 150 pounds and was not considered obese). On [DATE], R#1 received a standard LAL mattress ordered by Hospice. The bariatric bed frame was too large for LAL mattress which caused gaps between the mattress and assist rail. R#1 was found on [DATE] with her head and neck between the assist rail and mattress, expired. The resident had multiple areas of redness and bruising to her neck.
The IJ was related to the facility’s noncompliance with the program requirements as follows:
C.F.R. 483.25(n) Bedrails (F 700 Scope and Severity (S/S): J)
C.F.R. 483.21(b) Comprehensive Care Plans (F 656 S/S: J)
Additionally, Substandard Quality of Care was identified with the requirements at C.F.R. 483.25(n) Bedrails (F 700 S/S: J).
Review of the clinical record revealed that R#1 was found on [DATE] on the floor in a semi-upright position on her bottom lateral to the bed on the left side with her head positioned between the bed mattress and assist rail facing towards the door, expired. The resident was noted to be on a bariatric bed with a standard LAL mattress which left a gap between the mattress and assist rail.
The Physician Orders for R#1 between [DATE] at admission through [DATE] revealed no orders the use of assist/bedrails or a bariatric bed. R#1 did not have a care plan for a bariatric bed with assist rails.
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