Failure to Attempt Alternatives Before Installing All Four Bed Rails
Penalty
Summary
The facility failed to ensure that appropriate alternatives were attempted before installing all four bed rails for one resident. The resident in question had diagnoses including metabolic encephalopathy, dementia, and schizophrenia, and was assessed as lacking capacity to make decisions. Observations on two separate days showed the resident lying in bed with all four bed rails up, despite not using the rails for mobility or repositioning and being unable to remove them easily. The resident was dependent on staff for activities of daily living and was not receiving ADL assistance at the time of observation. A review of the physician's orders indicated that all four bed rails were to be up and locked for ADL changes, mobility, positioning, and as an enabler, and this was considered a non-restraint. However, staff interviews revealed that the resident was not able to use the bed rails for mobility and that the physician's orders did not match the resident's abilities. Documentation was not found to show that alternatives to bed rails were attempted prior to their use. Facility policy required that alternatives such as roll guards, foam bumpers, or lowering the bed be tried before bed rails were used, but there was no evidence this was done for the resident.