Failure to Assess, Document, and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure the correct installation, use, and maintenance of bed rails for multiple residents. Specifically, there was no documentation that the risks and benefits of bed rails were reviewed with the residents or their representatives, nor was informed consent obtained prior to bed rail installation for one resident. Additionally, for four residents who had bed rails in use, there was no evidence that an entrapment risk assessment was completed prior to installation. These deficiencies were identified through observations of residents in their beds with bed rails raised, interviews with CNAs and the DON, and reviews of clinical records that lacked the required documentation. The residents involved had significant medical conditions, including polyneuropathy, diabetes, morbid obesity, congestive heart failure, hemiplegia, paraplegia, and cerebral infarction. Despite these complex diagnoses and the presence of bed rails on their beds, the facility did not document the necessary assessments or obtain informed consent as required. Staff interviews confirmed the ongoing use of bed rails and the absence of documentation related to risk assessment and consent.