Failure to Obtain Bed Rail Consents, Inadequate Audits, and Improper Safety Testing
Penalty
Summary
The facility failed to provide required education and obtain informed consent for the use of bed rails for four residents with varying degrees of cognitive impairment and physical dependency. Clinical record reviews revealed that, despite physician orders and care plans indicating the use of side rails or grab bars, there was no documentation that residents or their representatives were educated on the risks and benefits, nor that consent was obtained prior to bed rail implementation. Interviews with the DON confirmed the absence of consent forms and education documentation, attributing the lack of paperwork to changes made by a previous DON. Additionally, the facility did not adhere to its own policy regarding the frequency and documentation of bed and side rail safety audits. Audit forms for the residents' beds lacked dates, and the Director of Maintenance acknowledged that audits were performed annually and on a random basis, rather than at the required six-month intervals. There was also no documentation of the specific dates audits were conducted, contrary to facility policy that mandates biannual assessments and proper record-keeping. Further deficiencies were observed in the performance of bed rail safety tests. During an observation, a bed rail was found to be loose, and the Director of Maintenance did not accurately perform the manufacturer-recommended entrapment test for a specific safety zone. Instead, the wrong test procedure was used, and the required zone was not assessed, with the Director unable to explain how the bed could be considered compliant without this critical test being completed.