Failure to Assess and Obtain Consent for Bed Rails and Grab/Transfer Bars
Penalty
Summary
The facility failed to assess the risks and benefits of bed rails or grab/transfer bars and did not obtain informed consent prior to their installation for four residents. For each of these residents, there was no documentation in the care plans or electronic health records indicating that an assessment for the appropriateness or risk of entrapment had been completed, nor was there evidence of informed consent from the residents or their representatives. Observations confirmed that grab/transfer bars were present and raised on both sides of the beds for these residents, and interviews with staff revealed uncertainty about the facility's policy and requirements regarding the use of such devices. The residents involved had significant medical histories, including conditions such as atrial fibrillation, dementia, Alzheimer's disease, lower extremity weakness, recent fractures, and severe cognitive impairment. Their care plans addressed issues such as impaired mobility, unsteady gait, fall risk, and the need for assistance with activities of daily living, but did not mention the use of bed rails or grab/transfer bars as interventions. In some cases, residents were unable to be interviewed due to cognitive decline, while one resident expressed concern about the placement of the rails near her head. Staff interviews indicated a lack of knowledge about the facility's policy on bed rails and grab/transfer bars, with some staff believing that assessments and consents were unnecessary for these devices. The administrator stated that the beds were received with grab/assist bars already installed and that they were not considered a risk or restraint, and therefore did not require assessment or consent. The facility's own policy, however, defined grab/assist bars as bed rails and required assessment, attempts at alternatives, interdisciplinary evaluation, and informed consent prior to use, none of which were documented for the affected residents.