Failure to Attempt Alternatives and Document Assessment Prior to Bed Rail Use
Penalty
Summary
The facility failed to attempt the use of appropriate alternatives prior to the installation of bed rails for a resident with dementia, epilepsy, and an anxiety disorder who required maximum assistance with bed mobility and transfers. Documentation showed that the resident's Power of Attorney (POA) requested bilateral half-side bed rails to enhance independent bed mobility, and a potential risk of entrapment was identified. However, there was no evidence that alternatives to bed rails were considered or attempted, nor were contraindications to alternatives identified. The facility's policy did not require the use of alternatives prior to bed rail installation, and the required risk-benefit assessment and documentation of attempted alternatives were missing from the resident's records. Further review revealed that the Bed Side Rails Decision Tree was incomplete, lacking the resident's name and documentation of the decision-making pathway. The DON confirmed that no alternatives were considered or attempted before implementing the bed rails, and the POA was not informed of alternatives or the benefits and likelihood of benefits of bed rails. The deficiency was identified through record reviews and interviews, which demonstrated noncompliance with regulatory requirements for assessing and documenting the use of bed rails.