Failure to Ensure Proper Installation of Bed Rails
Penalty
Summary
The facility failed to ensure the correct installation of bed rails for one resident. The resident, who had diagnoses including morbid obesity and bradycardia, was assessed as cognitively intact and had a care plan that included the use of a bariatric bed with bilateral bed rails to assist with mobility. The interdisciplinary care team recommended the use of bed rails, and informed consent was obtained from the resident. However, during an interview and observation, the resident reported that the bed rails were loose and shifted when used for support. Direct observation confirmed that the bed rails were visibly unstable and not properly affixed to the bed frame. Further investigation revealed that the bed rails were not secured to the bed frame and moved when the resident attempted to use them. The facility was unable to provide documentation that the bed rails were compatible with the bariatric bed frame or that they had been installed according to the manufacturer's specifications. The facility's policy required adherence to manufacturer instructions for bed rail installation, but this was not followed in this instance.