Failure to Obtain Physician Order and Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to obtain a physician order and informed consent prior to the installation of bilateral upper side rails for a resident. The resident, who was admitted with hemiplegia, hemiparesis, and dysarthria, was observed lying in bed with both upper side rails raised. The resident was noted to have right-sided paralysis and was dependent on staff for several activities of daily living. During interviews and record reviews, it was confirmed by the DON that there was no documentation in the resident's chart or electronic medical record indicating that a physician order or informed consent had been obtained before the side rails were installed. The facility's policy required that alternatives to bed rails be attempted and, if unsuccessful, that the interdisciplinary team assess the resident for risk of entrapment, review risks and benefits, and obtain informed consent prior to bed rail use. Despite these requirements, the necessary documentation and consent process were not completed for this resident, as confirmed by both observation and staff interviews.