Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
A deficiency occurred when a resident was found using full side bed rails without proper assessment, informed consent, or physician order, contrary to facility policy and federal regulations. The resident, who had diagnoses including Type 2 diabetes, lack of coordination, abnormal gait, and was on hospice care, had a documented refusal of bed rail use by their representative, and physician orders specifically indicated no side rails. The care plan did not address side rail use, and the Minimum Data Set (MDS) assessment also documented that bed rails were not used. Despite these records, multiple observations confirmed the resident was in a bed with full side rails up on both sides at various times. Interviews with staff revealed a lack of awareness regarding the resident's hospice status and the origin of the bed with full side rails, with some staff attributing the presence of side rails to the hospice-provided bed. The Director of Nursing and Administrator acknowledged the presence of full side rails and stated that their usual process involves assessment, consent, physician order, and care planning, none of which were completed for this resident. The resident was subsequently removed from the bed with full side rails after the deficiency was identified.
Plan Of Correction
F 700 On , the siderails for resident #45 were removed by the maintenance director. On , the Regional Nurse Consultant conducted a quality review of current residents with siderails to ensure that proper assessments and consents were in place. No additional findings were noted. By , current licensed nurses were educated by the Staff Development Coordinator on the components of F 700 with an emphasis on proper assessment and obtaining consent for bedrails. As part of a systematic change, newly hired licensed nurses will be educated on the components of F 700 with an emphasis on proper assessment and obtaining consent for bedrails. DON/Designee will conduct quality monitoring of 5 residents with siderails weekly x 4 weeks, then 10 residents with siderails monthly x 2 months to ensure that proper assessment and consents are in place. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met. F 700