Failure to Attempt Alternatives and Obtain Consent Before Bed Rail Use
Penalty
Summary
Staff failed to follow the facility's policy and procedure regarding bed safety and bed rails for one resident. Specifically, staff did not attempt alternative interventions before installing bilateral upper half side rails for a resident with severe cognitive impairment, dependence on staff for all activities of daily living, and multiple diagnoses including respiratory failure, dementia, and parkinsonism. During observation, the resident was found in bed with the side rails up, and staff confirmed the resident was confused. Record review and staff interviews revealed there was no documented evidence that alternative interventions were tried and found ineffective prior to the use of bed rails. Additionally, there was no signed informed consent for the use of the side rails in the resident's chart or electronic medical record. Both the LVN and DON confirmed that informed consent should have been obtained and documented, and that alternative interventions should have been attempted before installing side rails, as required by the facility's policy.