Failure to Assess and Obtain Consent for Bed Side Rail Use
Penalty
Summary
The facility failed to follow its own side rail policy and federal requirements regarding the assessment and consent for the use of bed side rails for four residents out of a sample of forty-nine. Observations revealed that these residents had raised upper quarter or half side rails on both sides of their beds. Interviews with staff confirmed that all beds in the facility are equipped with bilateral upper side rails and that side rail assessments are required on admission, quarterly, upon significant change, and annually. However, for the residents in question, there were missing or outdated side rail assessments and, in several cases, no documented consent for side rail use in the medical records. Specifically, one resident had only a single assessment from several years prior, and others had no consent forms or assessments available at all. Further review of the residents' medical records showed that some were totally dependent on staff for activities of daily living and unable to use side rails independently. Despite this, care plans for side rail use were initiated without the required ongoing assessments or proper consent documentation. Staff interviews confirmed that the facility's policy requires alternative devices to be tried first, assessments to be completed, and consent to be obtained and documented before side rails are used. These steps were not consistently followed, resulting in the deficiency.