Failure to Obtain Order, Consent, and Care Plan Prior to Bed Rail Use
Penalty
Summary
The facility failed to ensure proper procedures were followed prior to the installation and use of bilateral quarter upper bed rails for a resident diagnosed with Alzheimer's disease. Specifically, the bed rails were observed in use without a physician's order, and there was no timely development of a care plan addressing their use. Additionally, informed consent for the bed rails was not obtained from the resident's representative before the rails were installed. These actions were confirmed through observation, record review, and staff interviews, which revealed that the required assessment, order, care plan, and consent were all completed only after the bed rails had already been put in place. The resident's clinical record indicated that the bed rails were in use at all times while the resident was in bed to enhance mobility, but documentation showed that the necessary physician's order, care plan, and informed consent were not present at the time of installation. Staff interviews further confirmed that facility policy requires these steps to be completed prior to bed rail use, but they were not followed in this instance. The facility's own policies also specify that residents or their representatives must be informed of the risks and benefits and alternatives to bed rails, and that a comprehensive care plan must be developed, neither of which occurred before the bed rails were put in use.