Failure to Assess Alternatives and Risks Prior to Bed Rail Installation
Penalty
Summary
The facility failed to attempt alternative devices before installing bed rails on the beds of four residents, did not identify the specific medical needs to be met with bed rail use, and did not assess potential entrapment zones. For each of the four residents reviewed, documentation was lacking regarding the evaluation of alternatives to bed rails, and care plans did not consistently include interventions related to bed rail use prior to their installation. In several cases, sections of the interdisciplinary team (IDT) care conference forms related to positioning devices were left blank, and bed mobility device evaluations were either missing or incomplete. Residents involved had varying degrees of cognitive and physical impairment, including diagnoses such as stroke, dementia, and depression. Some residents required substantial or maximal assistance with bed mobility and transfers, while others had no functional impairment to upper or lower body. Despite these differences, the process for assessing the need for bed rails and documenting alternatives was not followed. In some cases, residents or their representatives were not informed about the use of bed rails or the associated risks and benefits prior to installation. Observations revealed that bed rails were in use for all four residents, and maintenance staff were responsible for installation and ensuring compatibility. However, bed rails were found to be loose in some instances, and maintenance staff were not always notified of issues. Manufacturer guidelines for the bed rails were not readily available, and there was a lack of clear process or policy for assessing entrapment risks. The facility's policy did not address the need to attempt alternatives before bed rail installation or provide resources for entrapment risk assessment.