Failure to Document Alternatives and Rationale for Bed Rail Use
Penalty
Summary
The facility failed to ensure that, prior to the placement of bed rails, alternatives were attempted and documented as unsuccessful in meeting residents' assessed needs. For four out of six residents reviewed for bed rail use, there was no documentation in the medical records regarding the evaluation of alternatives or the intended purpose for the use of bed rails. The facility's policy requires that the assessment include an evaluation of alternatives and documentation of their failure to meet the resident's needs before bed rails are installed. Specifically, residents with various diagnoses such as hemiparesis, diabetes, encephalopathy, respiratory failure, heart failure, osteomyelitis, and atherosclerosis were observed with bilateral upper side rails in place. In each case, the medical records lacked evidence of attempted alternatives or the rationale for bed rail use. Both the DON and the Administrator confirmed that this documentation was missing and should have been present in the residents' records.