Failure to Assess and Document Bed Rail Use and Alternatives
Penalty
Summary
The facility failed to ensure that a comprehensive and accurate assessment was completed for a resident regarding the use of four bed rails. The resident, who had diagnoses including metabolic encephalopathy, dementia, and schizophrenia, was admitted and readmitted to the facility and was documented as lacking the capacity to understand and make decisions. The Minimum Data Set (MDS) indicated the resident was dependent on staff for activities of daily living such as showering, toileting hygiene, and dressing. Observations on two separate days showed all four bed rails were up while the resident was in bed, and the resident was not using the bed rails for mobility or repositioning, nor was the resident able to remove the bed rails independently. Interviews with facility staff revealed that the need for all four bed rails had not been properly assessed, and alternatives to bed rails, as required by facility policy, had not been attempted or documented prior to their use. The facility's policy specified that alternatives such as roll guards, foam bumpers, lowering the bed, and concave mattresses should be considered before installing bed rails. Record review confirmed there was no documentation of attempted alternatives or a comprehensive assessment regarding the use of bed rails for this resident.