Failure to Provide Requested Bed Rails and Consult Resident
Penalty
Summary
A deficiency occurred when a resident who was alert, oriented, and his or her own decision maker, requested bed rails for repositioning and safety but was not provided with them. The resident had a physician's order for two quarter bed rails and a medical history including peripheral artery disease with bilateral foot gangrene, diabetic neuropathy, acute lymphoblastic leukemia in remission, chronic pain, and chronic urinary retention with an indwelling catheter. Despite the physician's order and the resident's expressed preference, the facility did not consult the resident regarding the use of bed rails, and the bed rails were not installed during the resident's stay. Interviews revealed that neither the resident nor the family were consulted about the bed rails, and staff members, including the nurse responsible for the bed rail assessment, did not recall completing the necessary assessment or obtaining consent. The Director of Nursing and Nurse Manager were unaware that the resident had not been consulted, and the Director of Rehabilitation did not recall assessing the resident for bed rail use. Facility policy required assessment and consent for bed rails upon admission, but this process was not followed, resulting in the resident's request not being addressed.