Failure to Attempt Alternatives Before Bed Rail Use
Penalty
Summary
The facility failed to attempt and document the use of appropriate alternative interventions before installing bilateral side rails for a resident. The resident in question had a history of hemiplegia, hemiparesis, and osteoarthritis, and was assessed as having severely impaired cognition. The resident was dependent on staff for all activities of daily living, including oral hygiene, toileting, showering, dressing, and personal hygiene. During observation, the resident was found in bed with both upper side rails raised, and staff confirmed the resident was confused and unable to move one side of her body. Record review and interviews with facility staff, including the DON, revealed there was no documented evidence that alternatives to side rails were attempted or evaluated prior to their installation. The facility's policy required that alternatives be tried and documented, and that an interdisciplinary evaluation and informed consent be obtained before bed rails are used. The lack of documented attempts at alternatives and evaluation placed the resident at risk for entrapment and physical injuries.