Failure to Assess, Obtain Consent, and Ensure Safe Installation of Bed Rails
Penalty
Summary
The facility failed to ensure that proper assessments, informed consents, and compatibility checks were completed prior to the installation and use of bed rails for two residents. Observations revealed that bed rails were in use on both sides of the beds for these residents, but there was no documentation of bed rail assessments, informed consent from the residents or their representatives, or evidence that the bed rails were compatible with the beds according to manufacturer guidelines. Staff interviews confirmed a lack of understanding and inconsistent practices regarding bed rail assessments, installation, and documentation, with some staff unaware of the requirements or the process for determining bed rail use. For one resident with a history of falls, dementia, and chronic ischemic heart disease, bed rails were observed in the up position on multiple occasions. However, neither the care plan nor the closet care plan indicated the use of bed rails, and staff were unsure if the resident was supposed to have them. The spouse of this resident reported never being informed about the bed rails or asked for consent. Maintenance staff responsible for installing bed rails admitted to not measuring beds for compatibility, not reading manufacturer guidelines, and not keeping records of maintenance or safety checks, despite acknowledging that loose bed rails could be unsafe. For another resident with multiple diagnoses including dementia and insomnia, bed rails were also observed in use, but the care plan and MDS did not reflect this. Staff interviews indicated that bed rails were already installed upon admission and that housekeeping, not nursing, installed them. The resident's family confirmed they were not informed about the bed rails, the risks involved, or asked for consent. There was also evidence of gaps between the mattress and bed rails, raising concerns about entrapment, and no documentation was found to support the safe and appropriate use of bed rails for either resident.
Removal Plan
- Provide in-service to Administrator by Regional Director regarding bed rails and assessing, getting signed consent and order prior to use.
- Administrator to provide in-service to nursing staff in person and via phone regarding policy and procedure of bed rails, assessing, consent to use and physician order requirement.
- Review records to be completed by nurse manager to identify other residents with bed rails.
- Identified residents will be assessed by nurse and consent obtained.
- Administrator and DON will monitor care areas weekly to ensure bed rails are assessed and consent obtained and in the record.
- Care plan and MDS will be updated by LPN Nurse consultant.
- IDT team will work with environmental services supervisor to ensure bed frame and bed rails are compatible for the provided bed per manufacturers guidelines and recommendations.
- Provide in-service by administrator to environmental service supervisor regarding bed rails, bed maintenance and ensuring bedrails and bedframe are compatible to prevent entrapment zones.