Failure to Assess and Document Alternatives Prior to Bed Rail Use
Penalty
Summary
The facility failed to comprehensively assess and attempt alternatives before the use of bed rails for a resident who had grab bars affixed to their bed. The resident had moderately impaired cognition and multiple diagnoses, including peripheral vascular disease, arthritis, hip fracture, dementia, Parkinson's Disease, and depression. Documentation showed that the resident required varying levels of assistance with mobility and activities of daily living. Although the care plan and order summary indicated the use of grab bars to promote independence, the quarterly Bed Rail/Assist Bar Evaluation noted that no bed rail or assist bar was in use at the time of assessment, and there was a lack of documentation regarding risk and benefit discussions with the resident or their representative. Observations confirmed that the resident used two grab bars during care, and interviews with staff revealed that assessments were completed but documentation of alternatives tried and family notification was missing. Review of evaluation forms and informed consent documents showed that sections for alternatives attempted and resident/representative notification were left blank. Staff acknowledged inconsistencies in completing assessments and documentation, and while there was a signed consent form, it did not include details about alternatives trialed or considered.