Failure to Obtain Informed Consent and Complete Quarterly Side Rail Assessments
Penalty
Summary
The facility failed to obtain informed consent for the use of side rails and did not conduct quarterly assessments for the risk of entrapment as required by its own policy. Specifically, for one resident with diagnoses including muscle wasting, chronic pain, osteoarthritis, and morbid obesity, the medical record did not contain evidence that a Side Rail Utilization Assessment had been completed quarterly. The facility's policy mandates that such assessments be performed upon admission, readmission, quarterly, or with significant changes, and that informed consent be obtained after discussing the risks and benefits with the resident or their representative. Observations confirmed that the resident was using bilateral hand assist rails during multiple surveyor visits, and interviews with the resident and the DON verified that the required assessment and consent process had not been completed as per policy. The resident, who was cognitively intact, reported using the rails for bed mobility, but documentation of the necessary assessment and consent was missing from the medical record.