Failure to Assess, Document, and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that residents were properly evaluated for the need and safety of bed rail use prior to installation. For three residents reviewed, there was no documentation of assessments, evaluations, or informed consent regarding bed rail use. These residents, who had various medical diagnoses including diabetes, dementia, cerebral infarction, COPD, visual loss, osteoarthritis, and moderate cognitive impairment, were observed with bilateral bed rails in use. Interviews with these residents revealed that none had been informed of the risks or benefits associated with bed rail use, and their care plans did not include any mention of bed rails or related bed mobility plans. Additionally, the facility did not document attempts to use alternatives to bed rails or reasons for the failure of such alternatives. Observations showed that all resident beds were equipped with some type of bed rail, and staff interviews confirmed that bed rails were not removed between residents. The facility lacked a policy for bed rail use, and there was no evidence of risk/benefit discussions or informed consent being obtained from residents or their representatives prior to the installation of bed rails.