Failure to Obtain Consent and Assess for Bed Rail Use
Penalty
Summary
The facility failed to ensure the correct use of bed rails and to assess residents for the risk of entrapment from bed rails for three residents observed with side rails. For one resident with non-traumatic brain dysfunction and moderate cognitive impairment, documentation for informed consent regarding the use of quarter side rails was not signed by the patient or their representative. The resident's care plan indicated the use of side rails as enablers for bed mobility, but interviews revealed the resident was unable to use the rails independently and required total assistance. The unit manager acknowledged that the required assessment and valid consent were not completed, and that reassessments had not been performed as required every three months. Another resident with unspecified dementia and moderate cognitive impairment also had quarter side rails in use, with the care plan specifying their use as enablers. However, the informed consent document for this resident was not signed by the family representative, rendering the consent invalid. The unit manager confirmed that the necessary consent was not obtained prior to the use of side rails for this resident. A third resident, with dementia and a history of femur fracture, was observed with quarter side rails in use on both sides of the bed. The resident required assistance with bed mobility and reported holding onto the side rails when repositioning. Review of the electronic health record revealed that neither a consent nor an assessment for the use of side rails was present. The unit manager confirmed that both the assessment and informed consent were missing for this resident. Facility policy requires assessment for risk of entrapment and informed consent prior to the use of side rails, but these steps were not completed for the three residents identified.