Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to complete required assessments and obtain informed consent for the use of bed rails for a resident. Observations on two separate occasions showed the resident in bed with a half bed rail in the up position. Documentation review revealed that the evaluation form for side rail use did not include an assessment for entrapment risk or consideration of alternatives prior to implementing the bed rail. The resident's annual assessment indicated a diagnosis of Alzheimer's disease with severe cognitive impairment, but there was no documentation of consent for the use of the bed rail. Interviews with staff confirmed that the resident used the bed rail for mobility and positioning, and that the only documentation completed was an assessment from several months prior. The DON acknowledged that no consent had been obtained and that alternatives to bed rail use had not been assessed or documented. Facility policy required both an assessment for entrapment risk and informed consent prior to bed rail use, but these steps were not followed for this resident.