Improper Bed Rail Installation and Assessment Leads to Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure that bed rails were installed and used in accordance with physician orders and proper assessment protocols for a resident. The resident, who had a history of multiple fractures, mood disorder, alcohol abuse, anxiety, insomnia, and chronic obstructive pulmonary disease, was assessed as cognitively intact but dependent on staff for most activities of daily living, including bed mobility and transfers. The resident's care plan and side rail assessment indicated a need for half rails on both sides of the bed, but the physician's order did not specify the size of the rails, and quarter rails were installed instead. The incident leading to the deficiency involved the resident getting her left arm caught between the bed rail while reaching for an item, resulting in a painful and displaced fracture of the left humerus. Staff interviews revealed that the resident frequently moved her arms through the side rails and used them for repositioning. The staff responsible for assessing and installing bed rails reported a lack of training on how to properly assess the need for side rails and how to determine the appropriate size or type of rail for each resident. Maintenance staff installed the rails that fit the bed without specific instructions regarding the size, and there was no clear communication between nursing and maintenance regarding the correct rail type. Documentation and interviews further indicated inconsistencies in the assessment and documentation process. The MDS did not list side rails as a restraint, as staff believed they were being used solely for bed mobility. There was also uncertainty among staff about whether the benefits of side rail use outweighed the risks for this resident, especially given her restlessness and history of injury related to side rails. The facility's policy required proper installation and maintenance of bed rails, but gaps in staff training and communication contributed to the improper use and installation of the bed rails, ultimately resulting in the resident's injury.