Failure to Obtain Physician Order for Bed Rail Use
Penalty
Summary
A deficiency occurred when a resident was observed using bilateral half side rails without a physician's order authorizing their use. The resident, who was admitted with a primary diagnosis of malignant neoplasm of the breast, was found lying in bed with the side rails up. The resident was confused and unable to answer questions at the time of observation. Review of the resident's medical records, including the physician order report covering the relevant period, confirmed that there was no documented physician's order for the use of side rails for this resident. Further review and interview with the nurse supervisor verified the absence of a physician's order for the side rails, despite facility policy requiring such an order, including documentation of diagnosis and medical necessity. The facility's policy treats side rails as physical restraints, necessitating a physician's order prior to use, which was not obtained in this case.