Improper Use of Four Bed Side Rails
Penalty
Summary
A deficiency was identified when a resident was observed in bed with all four side rails raised, contrary to the facility's policy and the resident's physician order, which allowed for a maximum of three side rails. The resident, who had a history of respiratory failure with hypoxia and congestive heart failure, required maximal assistance for activities of daily living but had intact cognition. During the observation, a CNA confirmed that only three side rails should have been raised and acknowledged that having all four up could make the resident feel trapped. Further review of the resident's records, including the Admission Record, History and Physical, Minimum Data Set, physician's orders, and the Side Rails Assessment, consistently indicated that no more than three side rails were to be used. The facility's policy also specified a three-rail maximum except under specific circumstances, which did not apply in this case. Staff interviews corroborated that the use of all four side rails was not appropriate and could be considered a restraint.