Failure to Assess, Document, and Provide Bed Rails per Physician Orders and Resident Consent
Penalty
Summary
The facility failed to ensure proper assessment, documentation, and implementation of bed rail use for three residents who were capable of making their own decisions. For one resident, although informed consent for bilateral quarter bed rails was obtained, the physician's order specified two grab bars, not bed rails, and the required bed rail assessment form was left blank. Despite this, bilateral quarter bed rails were observed in use for this resident. For two other residents, both had provided informed consent and had physician's orders and assessments supporting the use of bed rails. However, after these residents underwent room changes, bed rails were not installed on their new beds as per their orders. Both residents reported previously having bed rails and using them for bed mobility, but were left without them following the room change. The maintenance director confirmed that he was not informed of the need to reinstall bed rails after the room changes, and the process for communication between nursing and maintenance regarding bed rail installation was not followed.