Failure to Accurately Assess and Document Bedrail Use as Physical Restraints
Penalty
Summary
The facility failed to accurately assess the use of physical restraints, specifically bedrails, for four residents who were observed to have bedrails in use. Despite the presence of bedrails, the residents' care plans and Minimum Data Set (MDS) assessments did not document the use of these devices, nor did they identify them as restraints. In several cases, residents were cognitively impaired and unable to remove the bedrails themselves, which meets the definition of a physical restraint according to the CMS Resident Assessment User Manual. Interviews with staff revealed that there was no consistent process for obtaining provider orders, documenting the intended purpose of the rails, educating residents or representatives on risks and benefits, or obtaining consent for their use. Observations and interviews indicated that residents with significant physical and cognitive impairments were using bedrails without proper assessment or documentation. For example, one resident with hemiplegia and moderate cognitive impairment was unable to remove the rails and relied on them for support during care, yet this was not reflected in her care plan or MDS. Another resident with moderate cognitive impairment and multiple comorbidities had a bedrail installed, but the assessment did not confirm her ability to remove the device or document consent. Similar issues were found with two other residents, including those who were cognitively intact but dependent on staff for mobility and transfers, with no documentation of bedrail use in their care plans or MDS. Staff interviews further revealed a lack of clarity and consistency regarding the classification and assessment of bedrails. The DON and physical therapist considered the rails as assistive devices rather than restraints and did not follow restraint assessment protocols. There was no evidence of a policy guiding the accurate assessment of such devices, and staff were not consistently obtaining provider orders or documenting the necessary information regarding the use of bedrails. This resulted in a systemic failure to accurately assess, document, and monitor the use of physical restraints for residents using bedrails.