Failure to Implement Physician-Ordered Bed Rails for High-Risk Resident
Penalty
Summary
The facility failed to implement physician-ordered bilateral side rails for a resident who had been assessed as high risk for falls and had provided informed consent for their use. Despite a completed safety assessment, physician order, and signed consent form, the side rails were not installed for 37 days. The resident, who had a history of kidney transplant, congestive heart failure, pancytopenia, and an above-the-knee amputation, expressed feeling unsafe and reported that the trapeze alone was insufficient for his needs. The resident had specifically requested the side rails and completed all necessary documentation, but the intervention was not carried out. Interviews and record reviews confirmed that the facility's policy required assessment, informed consent, and proper installation of side rails when indicated. The Assistant Director of Nursing acknowledged that the order and assessment were completed, but the side rails were not implemented as required by policy. This lapse was observed during a site visit, where the resident was found lying close to the edge of the bed without the ordered side rails in place, despite being at high risk for falls and having mobility limitations.