Failure to Assess Alternatives and Entrapment Risk Prior to Bedrail Use
Penalty
Summary
The facility failed to ensure that alternative measures were attempted prior to the installation of side rails and did not complete proper assessments for the risk of entrapment for a resident reviewed for side rail use. Review of the resident's care plan and order summary indicated that side rails were implemented for enabling increased movement and for turning and repositioning, but there was no documented evidence in the electronic medical record that alternatives to side rails were considered or attempted before their use. Additionally, there was no documentation of an assessment for the risk of entrapment related to the use of side rails. Interviews with facility staff revealed that bedrails were routinely provided to residents upon admission without exploring alternatives, and staff were not aware of the requirement to consider alternatives prior to bedrail use. The LPN stated that nearly all residents received bedrails on the day of admission and that alternatives were not explored. The Maintenance Director confirmed that while monthly audits of bedrails were conducted for functionality and mattress fit, there was no formal assessment for entrapment risk, nor was there a device available to check for such risk. The DON also indicated a lack of awareness regarding the need to explore alternatives before bedrail use and stated that assessments were expected but not consistently performed.