Failure to Obtain Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure the correct use of bed rails for a resident, specifically by not obtaining informed consent prior to their installation. The resident in question, a female with a history of anoxic brain injury, muscle weakness, and rheumatoid arthritis, was found to have moderately impaired cognition. Despite the presence of physician orders for the use of 1/4 bed rails to promote independence and aid in repositioning, there was no documented informed consent from the resident or her representative. This oversight was confirmed through record reviews and an interview with the MDS nurse, who acknowledged the importance of obtaining consent to ensure the resident and family were aware of the risks associated with bed rail use. The facility's policy on bed safety and bed rails, revised in 2022, mandates that informed consent must be obtained before using bed rails, detailing the medical needs addressed by the rails and the potential risks involved. However, the resident's records showed a lack of consent documentation, and an observation confirmed the presence of bed rails on the resident's bed. This deficiency in practice could potentially affect other residents using bed rails, putting them at risk for injuries due to improper assessment and lack of informed consent.