Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
Facility B failed to assess residents for the use of bed rails, review the risks and benefits with the residents or their representatives, and obtain informed consent prior to installing bed rails for two of seven residents reviewed for accidents and hazards. The facility's policy required an interdisciplinary assessment, consultation with the attending physician, and input from the resident or legal representative before bed rails could be used, as well as documented consent and education about risks and benefits. However, interviews with staff, including the Administrator, DON, and MDS Coordinator, confirmed that no assessments or consents were obtained for the residents in question, and staff were unaware of the requirement to do so. Observations showed that both residents were found in bed with raised bilateral ¾ bed rails, and one resident was unable to independently lower the rails. Record reviews indicated that one resident was severely cognitively impaired according to a recent MDS, while a subsequent assessment showed cognitive intactness. Staff interviews confirmed that the bed rails were in use and that one resident requested them, but there was no documentation of assessment or consent. The facility's failure to follow its own policy and regulatory requirements placed these residents at risk for injury and restraint.