Failure to Assess, Obtain Consent, and Maintain Bed Rails
Penalty
Summary
The facility failed to follow its own policy and regulatory requirements regarding the use of bed rails for multiple residents. Specifically, the facility did not provide residents or their representatives with information about the risks and benefits of bed rail use prior to installation, nor did it obtain informed consent in several cases. For example, residents who were cognitively intact reported that staff had not discussed bed rail use with them, and in cases where residents had cognitive impairment and a designated Power of Attorney (POA), the POA was not notified or asked for consent. Documentation of consent or notification was missing for several residents. Observations revealed that bed rails were not properly installed or maintained for several residents. Multiple residents were found with loose or improperly positioned bed rails, and in some cases, the rails were installed perpendicular rather than parallel to the bed, contrary to proper installation procedures. Staff interviews indicated confusion and lack of clarity regarding responsibility for installation and ongoing maintenance, with maintenance staff stating that nursing staff were expected to tighten rails as needed, but the rails frequently became loose and were not consistently fixed. Additionally, there was a lack of communication and documentation regarding the maintenance and repair of bed rails. For instance, one resident reported a broken bed rail that had not been repaired for several days, and neither maintenance nor nursing staff were aware of the issue or had documented it in the maintenance log. These failures were observed across all reviewed residents who used bed rails, placing them at risk for injury, entrapment, and other negative health outcomes.