Failure to Obtain Informed Consent for Bedside Rail Use
Penalty
Summary
The facility failed to follow its own policy and procedure regarding the use of bedside rails for a resident with severe cognitive impairment and total dependence on staff for activities of daily living. The resident was admitted with diagnoses including chronic obstructive pulmonary disease, anxiety, and hypertension. The physician ordered bilateral side rails for turning, repositioning, and injury prevention, and the care plan required that the risks and benefits of side rail use be explained to the resident or their representative, with informed consent obtained prior to use. However, observations confirmed that the resident was using bilateral side rails, and interviews with the resident's representative revealed that no explanation of risks or benefits was provided, nor was informed consent obtained or documented. A review of the resident's clinical records confirmed the absence of a completed or signed informed consent for side rail use. The facility's policies, revised in 2024 and 2025, clearly required assessment, education, and documented consent before applying side rails. Staff interviews further confirmed that the required discussion and documentation did not occur, resulting in the resident and their representative not being given the opportunity to make an informed decision regarding the use of side rails.