Failure to Complete Required Bed Rail Assessments and Obtain Informed Consent
Penalty
Summary
The facility failed to follow its own policy and regulatory requirements regarding the assessment, documentation, and consent for the use of bed rails for two residents. Both residents had significant cognitive impairments and required substantial assistance with mobility and transfers. The facility's policy requires a comprehensive assessment of the resident's needs and risks, including the risk of entrapment, as well as a review of risks and benefits with the resident or their representative, and obtaining informed consent prior to the use of bed rails. These steps must be repeated at least quarterly or upon significant change in status. For one resident, the facility did not document the use of side rails on the Minimum Data Set (MDS), despite physician orders and care documentation indicating the use of assist rails for skin integrity and fall risk. The treatment administration record showed inconsistent completion of the intervention, and the care plan did not specifically address the need for repositioning bars. Although a side rail evaluation and verbal consent were obtained the previous year, there was no evidence of informed consent or re-evaluation at the most recent quarterly assessment. For the second resident, there was no current physician order for the use of repositioning bars, and the use of side rails was not documented on the MDS. The resident was identified as high risk for falls, with a history of falls and significant cognitive and physical impairments. The side rail evaluation and verbal consent were completed at admission, but no quarterly re-evaluation or updated consent was documented. Staff interviews confirmed that the residents did not use the repositioning bars independently, and the DON acknowledged that quarterly assessments and consents were not consistently completed as required by policy.