Failure to Obtain Informed Consent and Complete Bed Rail Assessments
Penalty
Summary
The facility failed to obtain informed consent for the use of bed rails for two residents and did not complete required assessments for the continued use of bed rails for three residents. Facility policy requires that before bed rails are used, staff must assess the resident for safety risk, review risks and benefits with the resident or their representative, obtain informed consent, and document these steps. However, for the residents reviewed, documentation of informed consent was missing, and assessment forms lacked signatures and information regarding the risks and benefits of bed rail use. For one resident with severe cognitive impairment and a history of falls and brain injury, bed rails were used to assist with bed mobility and positioning. Despite multiple assessments recommending bed rails, the sections for risks, benefits, and informed consent were left blank, and there was no evidence that the resident or their representative was informed or had provided consent. The facility was unable to locate the initial consent form, and progress notes did not document any informed consent or additional assessments for bed rail use. Another resident with severe cognitive impairment and physical debility also had bed rails in use for bed mobility and transfers. Although an evaluation noted the need for bed rails and that risks and benefits were discussed, there was no signature to validate informed consent. Similarly, for a third resident with severe cognitive impairment and generalized weakness, the initial consent was documented, but subsequent quarterly assessments lacked documentation of informed consent and did not include signatures. Interviews with facility staff confirmed that required quarterly assessments and consents were not completed, partly due to a change in the electronic medical record system.