Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to ensure that a resident with attached bed rails was comprehensively assessed for their use. The resident in question had no cognitive impairment and was independent with bed mobility and transfers, according to the quarterly Minimum Data Set (MDS), which also indicated that bed rails were not used. However, observations on two separate occasions showed that the resident had half bed rails up and locked on both sides of the upper half of the bed. The resident reported using the rails to reposition and assist with getting out of bed, and stated that the rails did not restrain movement. A review of the resident's medical record revealed a lack of assessment regarding entrapment risk, risk versus benefits, informed consent, bed dimensions in relation to the resident's height and weight, and documentation of alternatives attempted or contraindicated before installation. Interviews with facility staff, including the MDS coordinator and the DON, confirmed that no assessment was performed because the bed rails were considered adaptive equipment for mobility and transfers, not restraints. The facility's policy required documentation and assessment for bed rail use, but this was not completed in this case.