Failure to Complete Required Assessment and Consent Prior to Bed Rail Installation
Penalty
Summary
The facility failed to follow its established procedure for the installation of side rails for a resident. According to facility policy, prior to installing side rails, staff are required to complete a side rail evaluation to assess the resident for risk of entrapment, review the risks and benefits with the resident or their representative, obtain informed consent, secure a physician order, and update the care plan and kardex. Observation revealed that a resident had bilateral one quarter side rails installed on their bed, and both the resident and their sister confirmed that the rails were installed that afternoon at the sister's request due to recent falls. Record review showed there was no documentation of a completed evaluation or signed consent prior to the installation of the side rails. During interviews, the DON stated that the side rails were installed following a verbal request from the resident's mother and believed that a therapy admission evaluation sufficed as the required assessment. However, the DON later provided a side rail evaluation that was completed after the installation, indicating that the required assessment and consent process were not followed prior to the intervention.