Failure to Complete Bed Rail Safety Assessment Prior to Side Rail Use
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards by not conducting a required bed rail and mattress safety assessment prior to implementing the use of side rails. Multiple observations over several days showed that a resident's bed had both the top and bottom quarter rails in the upright position on one side, with the other side of the bed against the wall. The facility's policy requires an interdisciplinary evaluation of the sleeping environment, compatibility checks between bed components, and completion of a bed rail use assessment and informed consent prior to the use of side rails. However, documentation revealed that the bed rail/mattress safety assessment, bed rail use assessment form, and informed consent were not completed before the side rails were used for this resident. Interviews with the DON confirmed that the required assessments and consent forms were not completed prior to the use of both the upper and lower quarter side rails. Additionally, the DON acknowledged that the physician's order was only for the upper quarter rail to assist the resident with positioning, and that the lower quarter rail should not have been in the upright position. The facility had recently acquired new beds with non-removable side rails, but staff failed to ensure compliance with their own policy and procedures regarding bed safety and side rail use.