Failure to Obtain Orders, Consent, and Assessments for Bed Rail Use
Penalty
Summary
The facility failed to ensure proper procedures were followed regarding the use of bed rails for three residents. Specifically, there was no evidence of physician's orders, informed consent from the residents or their representatives, risk assessments for entrapment, or care plan documentation related to the use of assist rails. Observations confirmed that all three residents were using bed rails, and staff interviews acknowledged that required assessments, consents, and orders had not been obtained. Additionally, the facility did not have a policy in place for the use of bed rails. The residents involved had significant medical histories, including chronic conditions such as chronic kidney disease, heart failure, dementia, and a history of falls. Cognitive assessments indicated that at least two of the residents had moderate to severe cognitive impairment. Despite these factors, the facility did not document any individualized assessment or planning for the use of bed rails, nor did it obtain the necessary authorizations or consents prior to their installation and use.