Failure to Attempt Alternatives and Complete Bed Rail Assessments
Penalty
Summary
The facility failed to ensure the proper use of bed or side rails for multiple residents by not attempting alternatives prior to their use and not completing required assessments. Observations revealed that several residents were found in bed with bilateral upper bed rails in the upright position. Record reviews and interviews with the Assistant Director of Nursing (ADON) confirmed that the Side Rail Assessment forms for these residents were incomplete, with sections regarding alternatives left blank and no documentation indicating that alternatives were offered or attempted before implementing bed rails. The facility's policy requires that alternatives such as roll guards, foam bumpers, lowering the bed, or concave mattresses be attempted prior to bed rail use, but this was not documented for the affected residents. Additionally, the facility did not complete quarterly bed or side rail assessments for several residents as required. For some residents, only one assessment was found in their records, with significant gaps between assessments, and in some cases, the only assessment was outdated. The ADON confirmed that the required quarterly assessments, which should be completed with the Minimum Data Set (MDS), were not performed for these residents. These failures were identified through observations, interviews, and record reviews, and had the potential to place residents at risk of entrapment and serious injury.