Failure to Assess, Obtain Consent, and Document Bed Rail Use
Penalty
Summary
The facility failed to follow its own policy and regulatory requirements regarding the use of bed rails for three residents. Specifically, the facility did not assess residents for the risk of entrapment prior to the installation of bed rails, did not obtain informed consent from the residents or their representatives, did not secure physician orders for bed rail use, and did not update the residents' care plans to reflect the use of bed rails. These deficiencies were identified through record reviews, observations, and staff interviews. For one resident with diagnoses including type 2 diabetes, muscle weakness, heart failure, chronic kidney disease, and a history of repeated falls, there was no documentation of a bed rail assessment, informed consent, physician order, or care plan entry for the use of bilateral quarter bed rails, despite repeated observations of the resident with bed rails in the upright position. Another resident with acute necrotizing hemorrhagic encephalopathy, schizophrenia, muscle weakness, seizures, and lack of coordination was also observed with a quarter bed rail in use, but similarly lacked documentation of assessment, consent, physician order, or care plan inclusion for the bed rail. A third resident, who was cognitively intact and able to transfer with standby assistance, was observed with a right upper quarter bed rail in use. Record review confirmed the absence of a physician's order, care plan, or bed rail assessment for this resident. In all three cases, the Regional Director of Clinical confirmed that the required assessments, consents, orders, and care plan updates had not been completed prior to or during the use of bed rails.