Failure to Assess, Inform, and Obtain Consent Prior to Bed Rail Use
Penalty
Summary
The facility failed to follow its own policy and regulatory requirements regarding the use of bed rails for a resident. Specifically, staff did not review the risks and benefits of bed rail use with the resident or their representative, nor did they obtain informed consent prior to installation. Additionally, the required assessment for risk of entrapment from bed rails was not completed before the bed rails were put in use. These omissions were identified for one resident out of four reviewed for bed rail use. Observations over several days showed that the resident's bed consistently had both the top and bottom quarter rails in the upright position on the right side, with the left side of the bed against the wall. The resident was observed both in bed and in a wheelchair during these times. The resident had multiple diagnoses, including unspecified psychosis, lack of coordination, gait abnormalities, seizures, dementia, pseudobulbar affect, and intellectual disabilities. The physician's order specified the use of bilateral upper side rails for bed mobility assistance, safety, and security, but did not include the lower rail. Record review revealed that the bed rail/mattress safety assessment, bed rail use assessment form, and informed consent documentation were not completed prior to the use of the side rails. The DON confirmed that the lower quarter side rail should not have been in the up position and that the required assessments and consent had not been completed before the side rails were utilized. The facility's policy requires these steps to be taken before bed rails are used, but they were not followed in this case.