Failure to Assess and Document Alternatives Prior to Bed Rail Installation
Penalty
Summary
The facility failed to ensure that a resident was properly evaluated for bed rail use and that alternative measures were attempted prior to the installation of bed rails. According to the facility's policy, the use of bed rails is prohibited unless specific criteria are met, including the use of alternatives, an interdisciplinary evaluation, a resident assessment, and informed consent. For one resident with diagnoses including cerebral palsy, schizoaffective disorder, bipolar disorder, major depressive disorder, anxiety disorder, suicidal ideations, and paraplegia, there was no documentation of an initial bed rail assessment, alternatives tried, or consent for bed rail use. The resident was noted to be cognitively intact based on a Brief Interview for Mental Status (BIM) score of 15. Observations revealed a bed rail in the lowered position on the right side of the resident's bed, with the bed pushed against the wall on the left side. Staff interviews confirmed the presence of the bed rail and acknowledged that the required assessment, documentation of alternatives, and informed consent were not completed prior to installation. The Administrator and DON were unable to explain how the required documentation and interdisciplinary review were missed.