Failure to Ensure Accurate Assessment, Consent, and Documentation for Bed Rail Use
Penalty
Summary
The facility failed to ensure the safe and appropriate use of bed rails for a resident with severe cognitive impairment and total dependence on activities of daily living and mobility. The resident was observed with all four quarter rails raised and locked, but the facility's documentation did not align with the actual bed rail configuration in use. Specifically, the side rail assessment indicated full side rails on two sides, the physician's order called for bilateral half rails times four, and the consent form referenced quarter rails on two sides. None of these documents accurately reflected the four quarter rails that were actually in use for the resident. Additionally, the facility did not obtain informed consent that matched the physician's order or the actual bed rail setup. The consent form signed by the resident's representative described a different rail configuration than what was implemented, and there was no documented evidence that the risks and benefits of using all four quarter side rails were explained to the resident's responsible party. This created a lack of clarity regarding the intervention to which consent was given and whether the resident's representative was fully informed. Interviews with facility staff, including an LVN and the DON, confirmed these inconsistencies and acknowledged that the documentation did not accurately reflect the resident's needs or the actual intervention in place. Facility policies reviewed required that the risks and benefits of side rail use be explained and that documentation be complete and accurate, but these requirements were not met in this case.