Failure to Assess and Document Safe Use of Bed Rails and Side Rails
Penalty
Summary
The facility failed to ensure proper assessment and documentation for the use of bed rails and side rails for multiple residents. For one resident with severe cognitive impairment and total dependence on staff for activities of daily living, the facility did not complete required entrapment risk assessments and quarterly restraint assessments for both upper and lower side rails, despite physician orders and care plan interventions indicating their use. Observations confirmed that both upper and lower side rails were up, and staff interviews revealed that this was not in accordance with the resident's care plan and could restrict freedom of movement. For two other residents, both of whom had significant physical impairments but were cognitively intact, the facility failed to assess the risk of entrapment from bed rails prior to installation. Although physician orders and informed consent were documented, there was no evidence of an entrapment risk assessment before the use of side rails. Staff interviews confirmed that such assessments were not completed, and the use of side rails was primarily for safety, balance, and as an enabler for bed mobility and transfers. Additionally, another resident was found with all four side rails raised without an assessment for the need, safety, or informed consent for the lower side rails. Staff interviews indicated that the use of all four side rails was not ordered or assessed, and that this practice could restrict the resident's movement and be considered a restraint. The facility's policies required alternatives to be tried, interdisciplinary evaluation, and informed consent before the use of bed rails, as well as regular reassessment, but these procedures were not consistently followed for the residents involved.