Failure to Ensure Resident Free from Restraints Due to Improper Bed Rail Use
Penalty
Summary
A resident with diagnoses including chronic respiratory failure, heart failure, history of falls, bipolar disorder, and unsteadiness on feet was found to have a half side rail positioned on the bed in a manner that prevented voluntary exit from bed. The resident had moderate cognitive impairment and was unable to independently lower the side rail. Staff interviews confirmed that the side rail was routinely used for positioning and to prompt the resident to ask for help before getting up, but also acknowledged that the resident would have to scoot to the end of the bed or climb over the rail to exit, which was not considered safe. The Minimum Data Set (MDS) nurse, who lacked formal restorative nursing training, assessed the side rail for bed mobility but not as a restraint, and there was no restorative nurse on staff. Further review revealed that there was no physician's order for the use of side rails for bed mobility or positioning for this resident, and facility policy required assessment to determine if a bed rail meets the definition of a restraint. The policy defined a bed rail as a restraint if it restricts a resident from voluntarily getting out of bed due to inability to lower it independently. The Director of Nursing confirmed that the side rails were intended for positioning, not for fall prevention, and that documentation of alternatives or prior interventions was lacking. The facility failed to ensure the resident was free from restraints as required.