Failure to Ensure Proper Assessment, Consent, and Monitoring for Bed Rail Use
Penalty
Summary
The facility failed to ensure proper assessment, informed consent, and ongoing monitoring for the use of bed rails for three out of six residents sampled who had bed rails in use. For these residents, there were discrepancies between the documented assessments and the actual use of bed rails observed during the survey. Specifically, assessments either indicated that bed rails would not be used or were incomplete, yet bed rails were present and in use for these residents. Additionally, there was no evidence that the risks and benefits of bed rail use were explained to the residents or their representatives prior to implementation, and required consents were not found in the records. For one resident with a history of traumatic brain injury, above-the-knee amputation, and pressure ulcers, the care plan noted a high risk for falls and included the use of side rails as an intervention. However, there was no physician's order or completed assessment for bed rail use, and the resident's record lacked documentation of informed consent. Another resident with quadriplegia and a history of skin grafts had a bed rail in use for supporting personal items, but the assessment was incomplete and did not document risk factors or a full evaluation. A third resident with ALS and hand contractures also had bed rails in use, but the assessment was incomplete and did not address risk factors, and the most recent assessment stated that bed rails would not be used. Staff interviews revealed uncertainty regarding who was responsible for checking the functionality of bed rails and a lack of clarity about where documentation of risk communication and consent was maintained. The DON acknowledged that assessments were incomplete and that documentation of risk communication and consent was lacking. Observations confirmed that bed rails were in use for all three residents despite the absence of proper assessment, consent, and ongoing monitoring as required.