Failure to Assess and Obtain Consent for Bed Assistive Devices
Penalty
Summary
The facility failed to obtain consent for, assess the need for, and assess entrapment risks from bed assistive bars for two residents. For Resident 19, observations revealed the presence of assist bars mounted bilaterally at the head of her bed. However, the facility could not provide documentation of an assessment for the need of the assistive device, an assessment of potential entrapment risks, or consent obtained prior to the installation of the device. It was only after the surveyor's questioning that a new physician's order and relevant assessments and consent forms were completed. Similarly, for Resident 108, observations showed the presence of assist bars, but the facility lacked documentation of an assessment for the need of the assistive device, an assessment of potential risks, or consent obtained prior to the installation. The Nursing Home Administrator confirmed that Resident 108 was unable to use the assist bars, and there was no documentation to support their use. The deficiency was identified through observation, clinical record review, and staff interviews.
Plan Of Correction
1. Resident # 19 has been assessed for need, consented on the risk and benefits, and an entrapment inspection completed for her bed positioning device. Resident #108 no longer has bed positioning devices. 2. DON/designee will conduct a sweep to determine if other residents using siderails or positioning devices have a current assessment of need, risk and benefits consent, and a completed entrapment inspection on record. 3. Licensed Nurses and Rehab Staff will be educated on CFR Code 483.25(n) and the Center's policy regarding bedrail use in a skilled nursing facility. 4. DON/designee will conduct weekly sweeps to validate residents using bedrails or bed positioning devices have documented evidence of assessment of need, risk and benefit consent, and current entrapment risk inspection. Audit will be conducted weekly x 4 weeks, and then monthly x 3 months. Results of the audits will be submitted to the QAPI team. 5. Date of Compliance 1/30/2024