Failure to Assess and Monitor Bed Rail Risks
Summary
The facility failed to use alternatives to bed rails and did not adequately assess and monitor the risks associated with their use, leading to significant harm to residents. One resident, with a history of dementia and physical impairments, suffered a fractured arm after it became entrapped in the bed rail during care. The resident's care plan indicated a preference for bed rails to reduce anxiety, but there was no documented assessment of the risks versus benefits of their use. The incident resulted in a decline in the resident's physical condition, ultimately leading to hospice care and the resident's passing. Another resident, also with dementia and behavioral disturbances, was observed multiple times with her arm through the bed rail, posing a risk of injury. Despite the resident's documented history of hallucinations and agitation, there was no physician order for the use of side rails, and the facility failed to conduct a proper assessment of the risks associated with their use. The resident's care plan included the use of side rails for safety during care, but the facility did not adequately monitor or address the potential for entrapment. A third resident, who was immobile and dependent on staff for all mobility, had side rails installed at the request of the family without a proper assessment. The facility did not document any medical symptoms justifying the use of side rails, nor did they explore alternative methods to ensure the resident's safety. The lack of proper assessments and monitoring for all three residents highlights the facility's failure to comply with regulations regarding the use of bed rails, resulting in immediate jeopardy to resident safety.
Removal Plan
- Maintenance Director completed bed gap measurement and assessment for entrapment zones per FDA guidance for all residents' beds with side rails. All bed rails were in compliance.
- Maintenance Director completed side rail audit to ensure they are compatible with bed.
- Director of Nursing and Social Service Director audit of side rails used as a restraint or enabler with completed pre restraint assessment form, side rail assessment form, side rail usage assessment and side rail consent on all residents to ensure least restrictive alternatives.
- Director of Nursing and Social Service Director audit and update care plans for residents using side rails regardless of used as enabler or restraint and for any other residents with restraints other than side rails. Care plans include medical symptoms justifying use of restraint, type of restraint used, frequency, durations, circumstances for when it is to be used, interventions to address potential or actual complications from restraints use such as increase incontinence, decline in ADLs or ROM, increased confusion agitation or depression.
- Director of Nursing and Social Service Director audit completed of physician orders for side rails and correct as needed to include medical symptom being treated, type of restraint, frequency of releasing the restraint.
- Regional Director and Regional Director reviewed and updated Bed Rail Maintenance and Installation and Entrapment Prevention, Restraint Reduction Program, Restraint Policy, and Restraint Usage Guide.
- Education to clinical staff currently in the facility conducted by Administrator, Director of Nursing and Social Services Director on Restraint Policy, Restraint Reduction Program, and Restraint Usage Guide.
- Education to Maintenance Director completed by Corporate Director of Environmental Services.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Bed rail use without informed consent and without attempted alternatives. The DON could not provide documentation of informed consent before installing bed rails for two residents, including one resident with severe cognitive impairment, dementia, stroke with hemiplegia, and dependence for bed mobility and transfers. For another resident with moderate cognitive impairment, dementia, heart failure, and respiratory failure, the DON also could not provide documentation of alternative interventions attempted before four half rails were installed. Care plans and restraint/device assessments documented rail use, but one assessment had blank safety fields and the DON stated consent was not obtained because the rails were not considered a restraint.
Bed rails used without order, consent, or documented need. A resident with osteoarthritis, a recent knee replacement, and moderately impaired cognition was observed with bilateral siderails up even though the BRA said bed rails were not needed, the resident said they were not needed, and the EMR had no physician order or consent for their use. Staff and the facility P&P stated informed consent and a physician order were required before installation.
Failure to assess and document bed rail use for a resident with schizophrenia and depression. The resident was observed with one upper bed rail in the up position, but the chart lacked documentation of a resident assessment, alternatives tried, the purpose for the bed rail, a physician order, and a discussion of risks and benefits with signed consent. The DON stated the resident had not been assessed for bed rail use and should not have had the rail in use.
Failure to assess side rail entrapment risk and obtain informed consent. A resident with stroke-related weakness and no cognitive impairment used a side rail to get in and out of bed, but the EHR contained no consent for the rail and no entrapment zone measurements. Therapy notes described the bed assist rail as safe and helpful, while a later Bed Safety Evaluation only addressed a limited gap check and staff could not locate any entrapment checks or consent.
A resident with bilateral 1/4 side rails in use did not have a required Bed Rail Assessment completed. The resident had diagnoses including metabolic encephalopathy, abnormal posture, muscle weakness, and bilateral hip OA, and the care plan identified side rails as an enabler for transferring, repositioning, and ADL care. Staff stated the assessment should be completed before bedrails are implemented and then annually, but it had not been done for this resident.
Failure to obtain order and informed consent for bed rails: A resident with DM, depression, PVD, intact cognition, and bilateral AKA was observed in bed with half side rails on both sides. The LVN and DON stated there was no physician order or informed consent from the resident or representative before the rails were installed, despite the facility P&P requiring staff to explain benefits and hazards and obtain informed consent before using bed rails.
Bed rail use without informed consent and without attempted alternatives
Penalty
Summary
The facility failed to obtain informed consent before installing bed rails for 2 residents and failed to attempt bed rail alternatives before installation for 1 resident. Resident #4 had severe cognitive impairment with a BIMS score of 3, diagnoses including non-Alzheimer's dementia, stroke with right-sided hemiplegia, malnutrition, and anxiety disorder, and required substantial to maximal assistance with bed mobility and dependent assistance with transfers. The MDS identified daily use of a bed rail as a physical restraint, and the care plan described full bed side rail use for safety and independence with bed mobility, with instructions to discuss risks and benefits with the resident/family/caregivers and obtain a provider order when used as a restraint. The restraint/device/enabler assessment for Resident #4 identified one full side rail and one half side rail that prevented independent entry and exit from the bed when in use. The assessment indicated no other alternative measures were attempted or used, and listed risks and benefits of the device. During observation, the resident was in bed with the right side of the bed placed against the wall, a half rail upright on the right, and a full rail upright on the left with padding fixed to the inside of the rail. The DON stated the resident had used a low bed and fall mat before the full bed rail was implemented, but could not provide documentation of informed consent for bed rail use prior to installation. Resident #25 had moderate cognitive impairment with a BIMS score of 8, diagnoses including non-Alzheimer's dementia, heart failure, respiratory failure, and adjustment disorder with mixed anxiety and depressed mood, and was dependent on staff assistance for bed mobility and transfers. The care plan described top and lower half rails as an enabling device to promote independence, and another care plan addressed fall risk with interventions including a rail attempted with a pool noodle, a padded overlay, a low bed, and mattress/rail spacing checks. However, the restraint/device/enabler assessment for four half bed rails had blank responses for safety risk and additional safety measures, and the DON stated informed consent had not been obtained because the rails were not used as a restraint and could not provide documentation of alternative interventions attempted before installation.
Bed rails used without order, consent, or documented need
Penalty
Summary
The facility failed to implement its Policy and Procedure on the use of bed rails/siderails for Resident 64. Resident 64 was admitted with diagnoses including osteoarthritis and right knee joint replacement surgery. The Bed Rails Assessment dated 4/11/2026 indicated the resident did not need bed rails, and the Minimum Data Set dated 4/15/2026 showed moderately impaired cognition, supervision or touching assistance with oral hygiene, upper body dressing, and personal hygiene, partial/moderate assistance with toileting and lower body dressing, and dependence with showering. On 5/19/2026, surveyors observed Resident 64 sitting on the edge of the bed with bed rails/siderails up on both sides of the bed. CNA 2 stated the resident was able to sit, stand, and walk with supervision, and the resident stated the siderails were not needed and had not been requested. Record review showed no active order for bilateral 1/2 bed rails and no consent for their use in the EMR. Staff interviews confirmed that residents with bed siderails should have a physician's order and consent before installation, and the facility's P&P required informed consent after alternatives had been attempted and then a physician's order for the specified bed rail.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to ensure that, before a bed rail was placed in use, Resident #3 had a documented assessment that included alternatives attempted and how those alternatives failed to meet the resident’s assessed needs. The facility’s Proper Use of Bed Rails policy, reviewed on 6/5/25, required the resident assessment to evaluate alternatives tried before installation or use of a bed rail, assess the resident’s risk from using bed rails, obtain informed consent after alternatives were attempted, and then obtain a physician’s order for the specified bed rail and the medical reason for its use. Resident #3 was initially admitted and later readmitted to the facility with diagnoses including schizophrenia and depression. On 5/11/26 and 5/12/26, the resident was observed with one upper bed rail on the bed in the up position. On 5/12/26 at 10:05 AM, the medical record did not document a resident assessment, evaluation of alternatives attempted, the purpose for the bed rail, a physician order for the bed rail, or a documented discussion of risks and benefits with signed consent. At 1:42 PM, the DON stated the resident had not been assessed for the use of bed rails and should not have had the bed rail in use, but did.
Failure to assess side rail entrapment risk and obtain informed consent
Penalty
Summary
The facility failed to appropriately assess a side rail for entrapment zone risks and failed to obtain informed consent for side rail use for one resident reviewed for accident hazards. The resident had diagnoses including muscle weakness, hemiplegia, and hemiparesis following a cerebral infarction affecting the left non-dominant side. A quarterly MDS dated February 10, 2026, showed a BIMS score of 15, indicating no cognitive impairment. During observation and interview on May 6, 2026, the resident had a side rail attached to the right side of the bed, positioned in the down position but still several inches above the mattress, and stated that she used the side rail to get in and out of bed. When documentation was requested, the facility reported the records should be in the EHR, but no documentation was found for consent to use the side rail or for entrapment zone measurements. Therapy documentation from May and June 2025 noted the resident had received a bed assist rail and had been assessed as able to place and remove it safely, with improved bed mobility and good safety and management of the railing. However, a Bed Safety Evaluation dated March 19, 2026, only addressed whether there was a gap between the head or foot board and mattress and indicated that all questions had been answered yes, with rails/devices not required, and no further entrapment zone assessment was documented. Staff interviews confirmed therapy handled bed rail safety assessments but not entrapment zone assessments, and maintenance staff could find no entrapment zone checks or informed consent related to the resident's side rail.
Missing Bed Rail Assessment for Resident with Side Rails
Penalty
Summary
The facility failed to ensure that a Bed Rail Assessment was completed for one of eight sampled residents who had bed rails in use. Resident 1 was admitted with diagnoses including metabolic encephalopathy, abnormal posture, muscle weakness, and bilateral osteoarthritis of the hip. The resident’s MDS dated 6/29/2025 indicated the resident was cognitively intact. The care plan dated 1/21/2026 stated that bilateral 1/4 side rails were to be used while the resident was in bed as an enabler for transferring, repositioning, and during ADL care. Review of the resident’s Standard Assessments showed the Bed Rail Assessment was past due as of 2/6/2026. During observation on 5/7/2026, the resident was lying in bed with the head of the bed elevated and bilateral 1/4 side rails up. During interview, the RN stated Bed Rail Assessments are to be completed by the MDSC, LVN, or RN prior to implementing bedrails, and the MDSC stated that Bed Rail Assessments are completed upon admission and annually for residents who use bed rails and that one had not been completed for Resident 1. The facility policy titled Proper Use of Bed Rails stated the resident assessment should assess risks of entrapment between the mattress and bed rail or in the bed rail itself and determine whether the bed rail meets the definition of a restraint.
Failure to Obtain Order and Informed Consent for Bed Rails
Penalty
Summary
The facility failed to implement its Policy and Procedure on the use of bed rails for one sampled resident. Resident 106 was admitted with diagnoses including DM, depression, and PVD. The MDS dated 5/8/2026 indicated the resident had intact cognition and required varying levels of assistance with activities of daily living, including partial/moderate assistance with oral hygiene and upper body dressing, substantial/maximal assistance with toileting, showering, and lower body dressing, and dependence with personal hygiene. During an observation on 5/5/2026, Resident 106 was in bed with one-half bedrails up on both sides of the bed. Resident 106 stated that help was needed with bed mobility and had bilateral above-the-knee amputations. During a concurrent interview and record review, LVN 2 stated there was no physician order and no informed consent from the resident or representative before the bilateral half side rails were installed. The DON also stated that a physician order and informed consent should have been obtained before installation of siderails. The facility's undated Bed Safety and Bed Rails P&P stated that before using bed rails, staff shall inform the resident or representative about the benefits and potential hazards and obtain informed consent, including the assessed medical needs addressed and the resident's risks from bed rail use.
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