Failure to Implement Bed Rail Use According to Assessment and Policy
Penalty
Summary
The facility failed to ensure that side rails were implemented according to the resident assessment for one resident out of a sample of 24. The facility's policy requires that bed rails be used only after evaluation, care planning, and informed consent, with the least restrictive device chosen. For the resident in question, who was admitted with hemiplegia, hemiparesis, and an anoxic brain injury and assessed as having severe cognitive impairment, observations showed that four side rails were consistently in use on the bed, despite the assessment indicating only two upper side rails should be used. Multiple observations over several days confirmed the use of all four side rails, regardless of the resident's activity or position in bed. Review of the resident's side rail assessments, care plan, and physician orders revealed that only two upper side rails were indicated, and there was no documentation supporting the use of four side rails. Interviews with nursing staff and a CNA indicated a lack of awareness regarding the correct number of side rails to be used, with staff attributing the use of four side rails to the family having purchased the bed. The DON confirmed that only two side rails should be in use according to the assessment and that a physician's order and care plan should be in place for side rail use, which were absent.