Failure to Obtain Assessment, Consent, and Physician Order for Bed Rail Use
Penalty
Summary
The facility failed to obtain required assessments, consents, and physician orders for the use of bed rails for two residents. One resident, who was severely cognitively impaired, was observed multiple times with a padded bed rail in use, but there was no documentation in the electronic health record (EHR) of an assessment, consent, or physician order for the bed rail. Staff interviews confirmed that facility policy requires these steps before bed rails are used, and staff were unable to locate the necessary documentation for this resident. Another resident, who was moderately cognitively impaired, was observed with quarter bed rails and the bed positioned against the wall on several occasions. There were no physician orders or care plan entries addressing the use of bed rails or the bed's placement against the wall in the EHR. Staff confirmed that an assessment, consent, physician order, and care plan should have been in place for these interventions, but none were found for this resident.