Failure to Assess, Obtain Consent, and Use Alternatives Prior to Bed Rail Use
Penalty
Summary
Nursing staff failed to follow required procedures before the use of side or bed rails for four residents. Specifically, staff did not attempt to use less restrictive alternatives prior to installing bed rails, did not review the risks and benefits of bed rail use with the residents or their representatives, and did not obtain informed consent in several cases. Additionally, assessments for the safe use of bed rails were either not completed or not documented as required. For one resident with severe cognitive impairment and impaired vision, the care plan included the use of a side rail for bed mobility, but there was no documentation of the risks and benefits, no evidence of less restrictive alternatives being tried, and the consent form was incomplete and unsigned by a physician. Another resident with moderate cognitive impairment and multiple psychiatric diagnoses had a physician's order and care plan for side rail use, but there was no consent or assessment for the use of the side rail, and the last assessment indicated no side rail was in use. A third resident with moderate cognitive impairment, cerebral palsy, and seizure disorder had a care plan and physician's order for side rail use, but lacked both a consent and an assessment for the device. The fourth resident, who had no cognitive impairment but had bilateral lower extremity amputations, used a side rail for mobility and repositioning, but the consent did not include risks and benefits, and there was no documentation of less restrictive alternatives or a current reassessment. Interviews with the DON and ADON confirmed that required procedures, including obtaining consent, assessing for safety, and periodic reassessment, were not consistently followed.