Failure to Document Alternatives Prior to Bed Rail Use
Penalty
Summary
The facility failed to ensure that a resident had a documented risk assessment that included alternatives that had been tried and failed prior to the use of bed rails. The resident in question had diagnoses of major depressive disorder, Alzheimer's disease, cerebrovascular accident, and was noted to have severely impaired cognition, decreased mobility, blindness, and dementia. The care plan indicated the use of bilateral upper quarter bedrails to assist with bed mobility, and the facility's assessment documented that the resident's representative had given verbal consent for the side rails. However, the assessment did not include documentation of alternatives to bed rails that had been attempted and found ineffective, nor did it address drug classifications that could increase the risk of entrapment. Observations confirmed that the resident was using bilateral upper bed rails, and staff interviews revealed that side rail assessments were conducted at admission, quarterly, annually, and with significant changes. Staff also stated that the interdisciplinary team reviewed factors such as medication, mobility, mental status, safety awareness, and history of falls when making decisions about side rail use. Despite these procedures, the facility's policy required that appropriate alternatives be attempted before installing bed rails, and this was not documented in the resident's assessment, resulting in a deficiency.