Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to assess a resident for the use of a bed rail, as required by its own policy and regulatory standards. Specifically, the facility did not conduct an assessment to identify the reason for using the side rail or evaluate the risk of entrapment. There was no evidence of an interdisciplinary assessment, consultation with a physician or nurse practitioner, or input from the resident or their legal representative regarding the benefits and potential hazards associated with side rail use. Additionally, the facility did not obtain informed consent from the resident or their representative prior to the installation of the bed rail. The deficiency was identified for a resident who was admitted following a left proximal humerus fracture after a fall at home. The resident was cognitively intact but had functional limitations in the upper and lower extremity on one side. Observations showed a bed rail attached to the left side of the resident's bed, which the resident could not use for repositioning due to pain and limited mobility. Review of the medical record revealed no physician's order, no care plan, and no signed consent for the use of the bed rail, despite the facility's policy requiring these steps.