Failure to Obtain Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to review the risks and benefits of bed rails with Resident #12 or their representative and did not obtain informed consent prior to the installation of bilateral bed rails. The facility's policy required that residents be evaluated for the need and safety of bed rails, and that informed consent be obtained after discussing the risks and benefits. However, there was no documented evidence that these steps were followed for Resident #12, who had bilateral assist bed rails installed on their bed. Resident #12 had diagnoses including morbid obesity, heart failure, and respiratory failure, and was assessed as having intact cognition and independence with bed mobility and transfers. Despite this, the resident expressed a need for assist rails to maintain independence with bed mobility and avoid excessive desaturation. The facility's comprehensive care plan did not document the use of bed rails, and the resident did not recall being informed of the risks and benefits or signing a consent form. Interviews with facility staff revealed a lack of clarity and adherence to the policy regarding the use of bed rails. Staff members, including CNAs, LPNs, and the Rehabilitation Coordinator, acknowledged the importance of obtaining consent and documenting the use of bed rails in the care plan. However, it was noted that the process was not consistently followed, and many residents, including Resident #12, did not have the necessary documentation or consent forms completed, highlighting a systemic issue in the facility's compliance with its own policies.
Plan Of Correction
Plan of Correction: Approved March 14, 2025 Resident #12’s record was reviewed. Resident was evaluated for the appropriateness of bed rails. Resident was educated on risks and benefits of siderail use and consent was obtained on 2/13/2025. All residents with side rails were reviewed to ensure that education on risks and benefits of siderails was provided and consent was obtained. No other records were identified as deficient. All residents identified as having enablers or bed rails had a care plan that reflected their use and purpose. Clinical Nursing staff receive training on the bedrails policy and procedure including determination. The Director of Nursing will review records of all residents with siderails monthly to ensure that education on the risks and benefits was provided and that consent was obtained. The Audit tool will be reviewed quarterly with the Quality Assurance and Performance Improvement Meeting for 1 year to ensure compliance. Date of Correction: 2/13/2025 Person Responsible for Correction: Director of Nursing