Failure to Assess, Document, and Monitor Bed Rail Use
Penalty
Summary
The facility failed to provide ongoing assessment and monitoring of bed rails for a resident with quadriplegia and reduced mobility. The resident had bilateral bed rails in use without a current physician order, and the comprehensive care plan did not address the use of bed rails. Documentation showed that the last side rail consent form was completed over a year prior, with no evidence of ongoing informed consent, discussion of risks and benefits, or regular reassessment of the need for bed rails. Additionally, the care plan interventions did not include the use of bed rails, and there was no documented evidence that alternatives to bed rails were adequately attempted or evaluated. Quarterly side rail safety risk assessments were inconsistently completed, with significant gaps between documented assessments. Maintenance inspections for bed entrapment zones were performed only annually, and there was no evidence of regular maintenance or safety checks for the bed rails in use. Staff interviews revealed confusion regarding facility policy, with some staff believing bed rails were not permitted, while others stated the resident was allowed to keep them due to being "grandfathered in." Staff also indicated uncertainty about the frequency and requirements for ongoing assessments, consent, and physician orders related to bed rail use. Observations confirmed the resident was using bilateral bed rails and expressed a desire to keep them, primarily for support during wound care and bed linen changes. However, therapy and nursing documentation indicated the resident required total assistance for bed mobility and had limited functional use of their upper extremities, raising concerns about the appropriateness of bed rail use. The lack of a current physician order, comprehensive care plan inclusion, ongoing risk assessment, and regular maintenance constituted a failure to ensure the safe and appropriate use of bed rails for the resident.