Failure to Assess and Document Bedrail Use and Alternatives
Penalty
Summary
The facility failed to ensure that a resident, who was cognitively intact and made independent medical decisions, was properly assessed for the use of bedrails and that alternatives were trialed prior to their installation. The facility's policy required that the appropriateness of bedrails be evaluated in relation to the resident's condition, with documentation of alternatives explored, rationale for use, and the resident's cognitive ability. However, there was no documentation in the resident's medical record to support that an assessment for bedrail use was conducted, that alternatives were attempted, or that the continued use of bedrails was reassessed annually as required by policy. The resident, who had a history of left leg above the knee amputation, insomnia, generalized anxiety disorder, and repeated falls, was observed using bilateral quarter length bedrails. Staff interviews confirmed that the resident used bedrails for mobility and transfers, but the resident did not recall any discussion about the risks associated with bedrail use. A physical therapy screen noted the appropriateness of the bed setup but did not document any evaluation of alternatives or their outcomes. The Director of Nurses confirmed that no documentation existed to show compliance with assessment and policy requirements regarding bedrail use.