Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to complete necessary assessments and obtain informed consent for the use of bed rails for several residents, leading to a deficiency in care. Observations revealed that residents were using silver metal bilateral half siderails without proper documentation or consent. For instance, Resident #8, who has severe cognitive impairment and multiple medical conditions, was observed with siderails in use, but there was no consent or assessment found in their records. Similarly, Resident #14, who is cognitively intact, was using siderails without a physician's order or documented consent, and there was no monitoring for entrapment risks. The facility's care plans for the residents did not address the use, consent, assessment, or monitoring of the siderails. For Resident #19, the 'Informed Consent for Use of Bed Rails' form was incomplete, lacking documented assessments of medical needs, benefits, risks, and alternatives. Resident #43 also had an incomplete consent form, with no identification of the type or location of siderails to be used. These omissions indicate a systemic failure to adhere to the facility's policy on the proper use of bed rails, which requires thorough assessments and informed consent before installation. Interviews with facility staff, including the Director of Nursing and the Nursing Home Administrator, revealed a lack of awareness and compliance with the facility's siderail policy. The staff referred to the siderails as assist bars, and there was confusion about their proper use and documentation. The Director of Maintenance acknowledged that the silver siderails had been in use for a long time without proper evaluation or replacement. This lack of oversight and adherence to policy contributed to the deficiency in ensuring resident safety and compliance with regulatory standards.