Failure to Follow Bedrail Assessment and Consent Procedures
Penalty
Summary
The facility failed to follow its own policy and procedure regarding the use of bedrails for two residents. For one resident with dementia, Alzheimer's disease, and moderately impaired cognition, full bedrails were observed in use without any documented assessment for safety risk, physician's order, or informed consent prior to installation. The resident was dependent on staff for most activities of daily living, and staff confirmed that the required assessment and documentation were not completed before applying the bedrails. For another resident with anxiety disorder and muscle weakness, both upper side rails were found raised, and the resident reported never being asked for consent regarding their use. The resident had intact cognitive skills and required some assistance with daily activities. Facility staff, including the DON, confirmed that no alternatives were attempted, no physician's order was obtained, and no informed consent was documented before the bedrails were installed. The facility's policy required assessment, consideration of alternatives, and consent prior to bedrail use, but these steps were not followed for either resident.