Failure to Assess and Document Bed Rail Safety and Alternatives
Penalty
Summary
The facility failed to ensure that alternatives were attempted prior to the installation and use of bed rails for multiple residents. For six residents reviewed, there was no documentation that alternative interventions were tried before bed rails were installed. Additionally, the facility did not complete or document required assessments for the risk of entrapment, particularly when bed rails were used in combination with air mattresses, which is known to increase entrapment risk. There was also a lack of evidence that the risks and benefits of bed rail use were reviewed with residents or their representatives, and informed consent was not obtained or documented. For several residents, including those with significant medical conditions such as Parkinson's Disease, Multiple Sclerosis, morbid obesity, and cancer, the facility did not perform or document safety/gap tests between the mattress and bed rails. Comprehensive care plans and physician orders indicated the use of bed rails and air mattresses, but there was no evidence of updated bed rail assessments, ongoing monitoring, or audits of bed rails. Residents and family members reported not receiving education or information about the risks and benefits of bed rail use, and there was no written proof of consent in the medical records. Interviews with facility staff revealed confusion and lack of clarity regarding responsibilities for assessing entrapment risk, performing gap measurements, and maintaining documentation. The maintenance director and DON each believed the other was responsible for certain aspects of bed rail safety and assessment. There was no documentation of routine maintenance or audits of bed rails, and staff could not provide evidence of completed assessments or education provided to residents or families. The facility's own policy and FDA recommendations regarding bed rail safety and assessment were not followed, resulting in multiple deficiencies related to the safe use of bed rails.