Failure to Complete Required Side Rail Assessment and Consent
Penalty
Summary
The facility failed to follow required procedures before installing and utilizing bilateral quarter length side rails for a resident. Specifically, there was no evidence that alternatives to side rails were attempted, that an assessment for entrapment risk was conducted, or that the risks and benefits of side rail use were reviewed with the resident. Additionally, informed consent was not obtained prior to the installation and use of the side rails. These omissions were identified through observations, record review, and interviews with the resident and staff. The resident involved was admitted with acute and chronic respiratory failure, was cognitively intact, and had impairments in both upper and lower extremities, requiring substantial to maximum assistance with bed mobility. The resident was observed multiple times with the side rails in the raised position and stated she needed them for bed mobility and positioning. Interviews with staff revealed confusion regarding responsibility for completing the side rail assessment, with the admitting nurse indicating it was the Unit Manager's responsibility, while the DON and Administrator stated the admitting nurse should have completed the assessment. No documentation of the required assessment or consent process was found in the resident's electronic medical record.