Failure to Assess and Obtain Consent for Bedrail Use
Penalty
Summary
Surveyors identified that the facility failed to perform required bed rail assessments and obtain informed consent prior to the use of bedrails for multiple residents. In several cases, residents were observed with bedrails in use, but their electronic medical records did not contain documentation of a bed rail assessment or signed consent forms. For example, one resident was found in bed with bilateral bedrails and reported that staff had not discussed the use of bedrails, despite using them for mobility and bed exit assistance. The resident's record lacked a bed rail assessment at the time of review. Another resident was observed with half bedrails in place and stated that they had not requested or been asked about the need for bedrails, though they found them helpful for mobility. The electronic medical record for this resident did not include a Bed Side Rail Tool assessment, consent for use, or a device assessment for the bedrails. Similarly, a third resident reported that bedrails were already present upon admission and did not express a need for them, yet there was no documentation of assessment or consent in the record. A fourth resident was observed with half bedrails raised on both sides of the bed and appeared anxious and restless, attempting to get out of bed using the bedrail. The review of this resident's record also failed to reveal documentation of a Bed Side Rail Tool assessment. These findings demonstrate that the facility did not consistently assess residents for bedrail safety risks or obtain and document informed consent prior to bedrail use, as required.