Inaccurate Bed Rail Assessment and Use for Dependent Resident
Penalty
Summary
The facility failed to ensure that the bed rail assessment for a resident with significant functional limitations was accurate and that the use of side rails was appropriately indicated. The resident in question had contractures and impaired range of motion in both upper extremities, as documented in multiple assessments, including the Minimum Data Set and Occupational Therapy evaluation. Despite these limitations, a physician's order and a Bed Rail Safety Evaluation indicated that side rails were to be used to aid in bed mobility, and the evaluation inaccurately stated that the resident could move freely in bed without signs of impaired mobility. Observations and staff interviews confirmed that the resident was dependent on staff for all mobility and activities of daily living, and was unable to use the side rails due to contractures. During care, the resident did not reach for or hold onto the side rail when prompted, and staff acknowledged the resident's inability to use the rails. The Director of Rehabilitation Services also confirmed that the side rails could not aid the resident's mobility due to the functional limitations. The facility's policy required ongoing assessment to ensure bed rails met the resident's needs, but this was not accurately reflected in the resident's documentation or practice.