Failure to Properly Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to properly assess residents for bed rail use, as required by its own policy and regulatory standards. Specifically, three residents with multiple diagnoses, including malnutrition, cancer, history of falls, bipolar disorder, major depressive disorder, muscle weakness, dementia, and hypertension, were observed with bed rails in use. For one resident, no documentation of a bed rail assessment or risk versus benefit review was provided upon request. Another resident's care plan allowed for bed rail use at their discretion, but the corresponding assessment was incomplete, with several required questions left unanswered or marked incorrectly, and no evidence that the resident or family had been informed of the risks. The third resident's assessment form was also improperly completed, with most questions marked 'No' or 'NA', and there was no documentation of quarterly reassessment as required by policy. Staff interviews confirmed that previous assessments were not documented correctly, and the facility was unable to provide evidence that the required risk assessments, informed consent, and ongoing evaluations were conducted for these residents. The lack of proper documentation and assessment created a situation where residents were not adequately evaluated for entrapment or other risks associated with bed rail use, contrary to facility policy and best practices.