Failure to Ensure Proper Assessment, Orders, and Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure the proper use of side rails for two residents by not following established protocols for assessment, installation, and consent. For one resident with traumatic brain injury and functional quadriplegia, the care plan and physician's order specified the use of grab bars to assist with turning and repositioning in bed. However, observations and staff interviews confirmed that half side rails, rather than the ordered grab bars, were installed. Staff acknowledged that the installed side rails were not appropriate for the resident's needs and did not allow optimal use for mobility assistance as intended by the order and assessment. For another resident with generalized muscle weakness, hand contractures, and dementia, grab bars were installed on the bed without a corresponding physician's order at the time of observation. The order for grab bars was only entered after the issue was identified during the survey. Staff confirmed that an assessment had been completed recommending grab bars, but the required physician's order was missing until the day of the survey review. Additionally, the facility did not obtain informed consent from the responsible party for the use of grab bars immediately upon the resident's readmission, despite the grab bars being in use. The Director of Nursing confirmed that informed consent should have been obtained on the day of readmission to ensure the responsible party was aware of and agreed to the use of the device. The facility's own policy required assessment, order, and informed consent prior to the use of bed rails or grab bars.