Inaccurate Documentation of Bed Rail Use and Consent
Penalty
Summary
The facility failed to ensure accurate and consistent documentation regarding the use of bed side rails for one resident. The resident, who had diagnoses including dementia, hypertension, and dysphagia, and was assessed as having severe cognitive impairment and being dependent in activities of daily living and mobility, was observed with all four quarter rails raised on their bed. However, the side rail assessment documented in the medical record indicated the use of full side rails on two sides, which did not match the actual configuration in use. Additionally, the physician's order specified bilateral half rails times four, while the side rail consent form signed for the resident indicated quarter rails on two sides, further contributing to the inconsistency. Interviews with facility staff, including an LVN and the DON, confirmed that the documentation in the resident's record did not accurately reflect the physician's order or the actual bed rail setup. The discrepancies between the side rail assessment, the physician's order, and the consent form resulted in a lack of clarity regarding the type of side rails to be used and whether the resident's representative had consented to the correct intervention. The facility's policy required that documentation be objective, complete, and accurate, but this was not followed in the case of this resident.