Failure to Obtain Physician's Orders for Side Rail Use
Penalty
Summary
Nursing staff failed to obtain physician's orders for the use of bilateral side rails for two residents who had been assessed and recommended for side rail use upon admission. For the first resident, who had diagnoses including metastatic colon cancer, history of falls, change in mental status, pulmonary emboli, and ascites requiring a pleurx-drain, the informed consent form for bed rail use was signed, but the section indicating a physician's order had been obtained was left blank. Review of the resident's physician's orders confirmed that no order for side rail use was documented during the relevant period. For the second resident, who had a history of a fall with a right lower leg fracture, anxiety, depression, chronic pain, and ALS, the informed consent form was signed and the box indicating a physician's order had been checked. However, review of the physician's orders revealed no documentation of an order for bilateral side rail use. Interviews with nursing staff indicated a lack of understanding regarding the requirement for a physician's order, with one nurse believing the consent form itself served as the order and another unaware that the order was missing. The Director of Nursing was also unaware that the required orders had not been obtained.