Failure to Document and Justify Use of Bedrails as Restraint
Penalty
Summary
Facility staff failed to provide documented evidence that a non-ambulatory, cognitively impaired resident who required extensive assistance with bed mobility and transfers was not being restrained by the use of bedrails. The resident was observed on two separate occasions lying in bed with all four bedrails in the upward position. The resident's medical record included a physician's order for one-quarter side rails as an enabler to promote bed mobility, but there was no documentation supporting the use of all four bedrails. Additionally, the facility's own documentation requirements for physical restraints were not met, as there was no record of the date and time of restraint application, the type of restraint, the reason for use, monitoring, or assessment data. Interviews with the Administrator and Director of Nursing confirmed that the facility did not have a bedrail policy and acknowledged that the use of four bedrails would constitute a restraint, which was not supported by the resident's care plan or physician's order. The resident was dependent on staff for all bed mobility and transfers, had impairment in both upper and lower extremities, and was unable to participate in bed mobility independently. Despite these needs, the facility did not provide the required documentation or justification for the use of all four bedrails, resulting in a deficiency related to the improper use of physical restraints.