Failure to Attempt Less Restrictive Alternatives Before Grab Bar Use
Penalty
Summary
The facility failed to ensure that less restrictive alternatives were attempted prior to the installation and use of elevated grab bars for two residents. For both residents, medical record reviews showed that the required sections documenting the use of less restrictive alternatives and the residents' responses to those alternatives were left blank in the Side Rail Utilization assessments. Staff interviews confirmed that less restrictive measures were not offered or attempted before implementing the use of grab bars, despite facility policy requiring such steps. In both cases, staff indicated that the residents requested the grab bars, but acknowledged that alternatives should have been tried and documented as part of the assessment process. One resident, who had moderate cognitive impairment and required moderate to dependent assistance for mobility, was observed using bilateral grab bars for repositioning in bed. The other resident also had a physician's order for bilateral grab bars for bed mobility, transfers, and repositioning, and was observed using them. Facility policy required interdisciplinary evaluation, resident assessment, and informed consent, as well as the use of alternatives such as roll guards or foam bumpers before bed rails or grab bars were installed. The failure to follow these procedures was verified by the ADON, DON, and other staff during interviews and record reviews.