Failure to Complete Bed Rail Assessments, Attempt Alternatives, and Care Plan for Bed Rail Use
Penalty
Summary
The facility failed to complete required bed rail entrapment assessments for all 48 residents who used bed rails. Observations revealed that multiple residents had bed rails in use, but their clinical records did not contain documentation of entrapment risk assessments. Interviews with the maintenance director (MD) and director of nursing (DON) confirmed that there was no coordination between departments to assess the risks of entrapment or to ensure that bed rails were appropriate for the size and weight of each resident. The MD stated that bed rails were installed or removed based on nursing staff requests and resident needs, but no adjustments were made according to resident size, and no documentation of safety monitoring was provided. Additionally, the facility did not attempt alternative measures before implementing bed rails for six residents. Review of physical restraint assessments for these residents indicated that alternatives were not considered or documented prior to the use of bed rails. The DON confirmed that nursing staff did not complete assessments for alternative interventions before starting bed rail use for these residents. Furthermore, one resident who had an order for bilateral half side rails did not have a separate and specific care plan addressing the use of side rails. The DON verified that this resident's care plan did not include information about the use of side rails and acknowledged the omission. These failures were identified through observation, record review, and staff interviews.