Failure to Follow Bed Rail Assessment and Documentation Procedures
Penalty
Summary
The facility failed to implement and operationalize its policies and procedures regarding bed rail use for one resident. The resident was observed in bed with side rails present, but there was no evidence in the medical record of a health care provider order, assessment, or monitoring for the use of bed rails. The facility's own policy requires a physician order, initial and ongoing assessments, informed consent, and documentation of risks and benefits before bed rails are used, none of which were found in this case. The resident involved had a history of left lower limb monoplegia, schizophrenia, depression, and traumatic brain injury, and was cognitively intact but required assistance with activities of daily living. The care plan referenced a previous fall and included education on the use of half rails and call lights, but there was no separate or current care plan specifically addressing bed rail use. Documentation showed that after a fall, the resident was educated on using side rails for bed mobility, but no formal assessment, consent, or provider order was documented. Interviews with the DON and a clinical RN confirmed that the required documentation, including a physician order and assessment for bed rail use, was missing from the resident's record. The facility's policy outlines a comprehensive process for evaluating and documenting bed rail use, including alternatives, risk assessment, and informed consent, but these steps were not followed for this resident.