Failure to Obtain Required Authorization and Documentation for Bedrail Use
Penalty
Summary
The facility failed to obtain a physician's order, informed consent, a bedrail assessment supporting use, and a care plan for the application of padded bilateral upper bedrails for a resident with hemiplegia, hemiparesis, muscle weakness, and cognitive communication deficit following a cerebral infarction. The resident was admitted with high fall risk and required assistance with mobility and activities of daily living, using both a walker and wheelchair. Despite the resident's capacity to make medical decisions and intact cognition, there was no documentation of a physician's order or informed consent for the use of bedrails. Observation confirmed that the resident's bed had bilateral upper padded bedrails in use, and staff interviews revealed that the bedrails were being used to facilitate mobility in bed and as a fall intervention. However, review of the resident's records showed the absence of a physician's order, informed consent, and a care plan addressing the use of bedrails. The only bedrail assessment present recommended against their use, yet the bedrails remained in place. Interviews with facility staff, including the Director of Staff Development and the Assistant Director of Nursing, confirmed that required procedures were not followed. Facility policy required a detailed healthcare provider order, informed consent, and care planning for bedrail use, but these steps were not completed. The lack of proper assessment, documentation, and consent for the use of bedrails constituted the deficiency identified by surveyors.