Failure to Assess and Obtain Consent for Bed Rail Use Resulting in Physical Restraint
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints by not performing required assessments and not obtaining proper physician orders prior to the use of bed rails. Specifically, two residents were found with both upper and lower side rails raised on their beds, despite only having consent and physician orders for the use of upper side rails. Facility policy requires a comprehensive assessment, informed consent, and physician order before implementing bed rails, as well as consideration of alternatives and evaluation of potential risks such as entrapment. For one resident, who had diagnoses including metabolic encephalopathy, acute respiratory failure with hypoxia, and congestive heart failure, records showed dependency on staff for all activities of daily living and limited mobility. Although there was informed consent for upper side rails, observations revealed that both upper and one lower side rail were up. Facility leadership confirmed that the lower side rail should not have been raised without proper assessment and consent, as it could be considered a restraint and posed a risk of entrapment. A second resident, admitted with conditions such as adult failure to thrive, dysphagia, and major depressive disorder, also required substantial assistance with daily activities. This resident had a physician's order and informed consent for bilateral upper half side rails only. However, during observation, both upper and one lower side rail were found raised. Staff interviews confirmed that the lower side rail should not have been up and could be dangerous. Review of facility policies reiterated that bed rails are prohibited unless all criteria, including assessment and consent, are met.