Failure to Assess, Document, and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that proper assessments and informed consent procedures were followed prior to the use of bed rails (enabler bars) for three residents. Specifically, the facility did not assess these residents for safety risks, did not attempt less restrictive alternatives before installing bed rails, and did not document that the risks and benefits were reviewed with the residents or their representatives. In addition, informed consent for the use of bed rails was not obtained or documented for these residents. For one resident with severe cognitive impairment and multiple diagnoses including cerebral infarction, vascular dementia, and a history of falls, bed rails were observed in use despite the care plan and MDS assessment not reflecting their use. The enabler review was only completed during the survey and did not document alternative interventions attempted, the risks of using the bed rails, or whether these risks were explained to the resident or representative. Staff interviews revealed a lack of awareness regarding the risks associated with bed rails and uncertainty about who was responsible for obtaining informed consent. Two other residents, one with moderate cognitive impairment and hemiplegia, and another with severe cognitive impairment and dementia, also had bed rails in use without prior physician orders, proper documentation in their care plans, or evidence of informed consent. In both cases, the enabler reviews were completed during the survey and failed to document alternative interventions or the risks of bed rail use. Staff interviews indicated confusion about the assessment process, the need for consent, and the safety checks required for bed rails, with some staff unaware of potential safety concerns such as gaps between the bed rail and mattress.