Failure to Assess, Document, and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to follow required protocols regarding the use of bed rails for four residents. Specifically, the facility did not attempt alternative devices before installing bed rails, did not conduct or document comprehensive assessments for risk of entrapment, and did not review the risks and benefits of bed rail use with the residents or their representatives. Informed consent was not obtained, and there was no evidence that the facility ensured the bed rails were appropriate for the residents’ needs or that bed dimensions were suitable. These failures were identified through observation, interviews, and record reviews, which revealed that bed rails were in use without proper documentation or assessment. For each of the four residents reviewed, therapy evaluations and care plans did not indicate the presence or need for bed rails. Device assessments, when present, were incomplete and did not document attempts at less restrictive alternatives, the resident’s ability to remove the device, or the acquisition of informed consent. In several cases, residents and their families were not educated on the risks and benefits of bed rail use. Some residents were unaware of the purpose of the rails or how to remove them, and staff interviews revealed a lack of understanding regarding the safety risks associated with bed rails. Maintenance and nursing staff described a process for installing rails that did not include physician orders or consent, and the DON and other staff believed the rails were not considered restraints, relying on manufacturer documentation rather than regulatory requirements. Observations confirmed that residents had bed rails in place, sometimes in configurations that were not consistent or clearly documented. Residents reported using the rails for safety or mobility, but there was no evidence that the facility had assessed whether the rails posed a risk of entrapment or were the least restrictive option. The facility’s own policy required device assessments, orders, and consents for side rails, but these steps were not followed in practice. The lack of proper assessment, documentation, and education contributed to the deficiency identified by surveyors.